Sulcular translation flap in secondary bone grafting: retrospective study of 72 alveolar cleftsInternational Journal of Oral and Maxillofacial Surgery


M. Paris, R. Paquin, A.-C. Valcourt
Surgery / Oral Surgery / Otorhinolaryngology


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Cleft Lip and Palate

Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx, available online at http://www.sciencedirect.comSecondary alveolar bone grafting in the cleft patient population is a surgical technique that is well defined in the current literature. In fact, 75% of patients with a labial cleft will present an alveolar defect.1,2 This defect is characterized by a three-dimensional inverted pyramid: the nasal floor and nasal mucosa represent the superior portion and the palatal and gingival mucosae form the laterals walls.3,4

Different goals can be achieved with secondary bone grafting, such as the closure of vestibular or palatal fistulas, achieving periodontal health and integrity, maxillary continuity and stability, which allow nasal, alar base, and labial support and subsequent orthodontic movement.1,4–11 Such alveolar cleft continuity may be achieved with an iliac crest bone graft, which was described by Boyne and Sands in 1972.12 During alveolar grafting, the presence of an incompetent orbicular or a large vestibular fistula needs to be addressed with a concomitant cheilorhinoplasty.13 Preoperative orbicularis oris dysfunction or large vestibular 0901-5027/000001+06 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.Sulcular translation flap in secondary bone grafting: retrospective study of 72 alveolar clefts

M. Paris, R. Paquin, A.-C. Valcourt: Sulcular translation flap in secondary bone grafting: retrospective study of 72 alveolar clefts. Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx. # 2015 International Association of Oral and Maxillofacial Surgeons.

Published by Elsevier Ltd. All rights reserved.

Abstract. Secondary bone grafting from the iliac crest is the gold standard in the reconstruction of maxillary alveolar bone defects in cleft patients. Numerous techniques for this graft have been described, although none is considered clearly superior at this time. A retrospective chart study was performed of 72 alveolar clefts in 59 patients who underwent an alveolar iliac crest bone graft with nasal floor reconstruction, with or without concomitant secondary cheilorhinoplasty. Fortyfour patients were included in the bone grafting group and 15 in the concomitant cheilorhinoplasty group. Both groups had a sulcular translation mucoperiosteal flap with anterior repositioning of the gingival papilla as the preferred intraoral flap technique. One-third of patients had undergone previous attempts at oronasal fistula closure. Results showed 100% Bergland stage 1 in the cheilorhinoplasty group and 96% in the bone graft group. Two failures (stage 4) were observed in the bone graft group. The infection rate was 9% in the cheilorhinoplasty group and 2% in the bone graft group. Of clefts in the bone graft group, 10% showed postoperative residual fistulas; none were observed in the cheilorhinoplasty group. The sulcular translation flap is a simple surgical approach and shows a low complication rate.Please cite this article in press as: Paris M, et al. Sulcular translation flap in secondary bone clefts, Int J Oral Maxillofac Surg (2015), words: alveolar cleft; secondary bone grafting; gingival flap; fistula.

Accepted for publication 14 April 2015M. Paris, R. Paquin, A.-C. Valcourt

Department of Oral and Maxillofacial Surgery,

Centre Hospitalier Universitaire de Que´bec,

Quebec City, CanadaClinical Papergrafting: retrospective study of 72 alveolar fistulas are attendant problems that can complicate gingival closure and lead to postoperative complications.

Many surgical techniques are described to access an alveolar cleft defect at the time of bone grafting. Various studies have shown the impact of soft tissue covering and mobilization without tension during secondary bone grafting, allowing good functional and aesthetic results.5,11,14,15 Decision-making related to the selection of the gingival approach has become a primary step in alveolar bone defect correction to ensure long-term success.15 The mucoperiosteal rotational cleft after bone grafting and classified radiological bone filling into four different stages depending on the alveolar bony fill obtained for the adjacent teeth (Table 1).

Stages 1 and 2 represent a successful outcome, permitting prosthodontic rehabilitation with minimal alveolar, aesthetic, and functional discrepancies.21 Bone graft months postoperatively. This classification evaluates alveolar bone filling following alveolar grafting; four stages are described (Table 1). In the literature, stages 3 and 4 are considered bone graft failure.11,21 The radiological evaluator was unaware of whether or not the patient 2 Paris et al.

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Table 1. Classification of the alveolar process p

Stage 1 Complete alv

Stage 2 More than th

Stage 3 Less than thr

Stage 4 Absence of b showing two 60-degree triangular flaps. (B) Flap ction in vestibular depth.finger flap,10 buccal flap with Z-plasty,10 vestibular flap,7 and translational sulcular flap10,16–20 are described in the literature.

There is still no consensus regarding the best gingival approach and none has yet become the surgical gold standard. The finger flap involves rotation of the free gingiva without the attached gingiva and may lead to periodontal complications and a reduction in the depth of the vestibule.10,21 Multiple cleft teams favour the translational sulcular flap.10,16–20 This gingival approach involves a sulcular incision with a distal releasing incision on the cleft side. After alveolar cleft repair and bone graft insertion, the gingival papilla is transpositioned anteriorly allowing tension-free closure with better quality of soft tissue and bone graft coverage.17 Additionally, the Z-plasty flap is often considered for large alveolar defects (Fig. 1).10 It allows flap lengthening and greater mobilization.10 Regardless of the surgical approach that is chosen, gingival recession remains a common complication, which can be prevented by adequate flap selection and sufficient flap mobilization.5