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Table of Contents
TECHNICAL NOTE
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 27-31

Platelet-rich fibrin in the Alveolar Bone graft in cleft lip and palate patient


1 Division of Oral and Maxillofacial Surgery, Craniofacial Anomalies Treatment Center, Rio de Janeiro State University, Rio de Janeiro; Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, São Paulo, Brazil
2 Division of Oral and Maxillofacial Surgery, Craniofacial Anomalies Treatment Center, Rio de Janeiro State University, Rio de Janeiro; Fluminense Federal University, Niterói, Brazil
3 Division of Plastic Surgery and Chairman, Craniofacial Anomalies Treatment Center, Rio de Janeiro State University, Rio de Janeiro, Brazil

Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Bruno Santos de Barros Dias
Division of Oral and Maxillofacial Surgery, Craniofacial Anomalies Treatment Center, Rio de Janeiro State University, Av. Marechal Rondon, 381, Sao Francisco Xavier, Rio de Janeiro
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GFSC.GFSC_4_18

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  Abstract 


Reconstruction of the alveolar ridge in patients with cleft lip and palate can be a challenging procedure. This stage of the treatment allows stabilization of the dental arch, adequate dental eruption, and orthodontic movement in the area of the cleft. Hence, it should be performed before the eruption of the permanent canine. Failure mainly occurs by dehiscence, exposure, and contamination of the bone graft. Adequate dissection, the definition of anatomical planes, and precise suture are paramount for a good result. However, this is often not enough. Sometimes, there is an anatomical limitation to make a suitable soft-tissue scaffold to be filled with bone graft. The lack of a hermetic closure of the anatomical planes can lead to contamination of the graft or even prevent its accomplishment in the same surgical time. Growth factors have been widely used in dentistry, with striking results in bone and tissue regeneration. Among these, platelet-rich fibrin is distinguished by allowing it to be made an autogenous membrane. This membrane supports exposure to the oral cavity without contamination and can stimulate the healing of soft and bony tissue, acting as a physical barrier. Its use as a growth factor and protective barrier of the alveolar bone graft in patients with cleft lip and palate is a promising tool for obtaining better results.

Keywords: Alveolar bone graft, cleft lip, cleft palate, platelet-rich fibrin


How to cite this article:
de Barros Dias BS, Schneider T, Ladvocat Cintra HP. Platelet-rich fibrin in the Alveolar Bone graft in cleft lip and palate patient. Int J Growth Factors Stem Cells Dent 2018;1:27-31

How to cite this URL:
de Barros Dias BS, Schneider T, Ladvocat Cintra HP. Platelet-rich fibrin in the Alveolar Bone graft in cleft lip and palate patient. Int J Growth Factors Stem Cells Dent [serial online] 2018 [cited 2019 Aug 24];1:27-31. Available from: http://www.cellsindentistry.org/text.asp?2018/1/1/27/230071




  Introduction Top


The chronology of the cleft lip and palate patient's treatment is well determined by the literature. That is important to achieve suitable growth, function, and esthetic results.

The alveolar bone graft (ABG) should be performed before the irruption of the permanent canine usually between 9 and 12 years of age. The goals of this phase of the treatment should be:[1],[2],[3]

  • Establish of adequate alveolar ridge and nasal floor anatomy
  • Eliminate of oronasal fistula, improve the status of oral hygiene
  • Long-term dental and periodontal health in the teeth adjacent to the cleft
  • Allow teeth movement through cleft area, which is necessary to establish normal occlusion
  • Provide suitable bony architecture on which to perform symmetric nasolabial muscle reconstruction.


To provide adequate surgical planning is important to observe the pyramidal design of this skeletal defect pattern.[2] The critical area of the defect is located at the apex of this pyramid, which corresponds to the posterior region of the nasal mucosa. Often, failure of bone graft is due to the suture dehiscence in this area, which may lead to contamination with partial or total loss of the bone graft.

The positive impacts of the platelet-rich fibrin (PRF), such as accelerated healing, decreased risk of infection, less postoperative discomfort, and fast recovery, can be added by the ability to behave as a membrane, functioning as a biological and physical barrier.[4],[5]

The aim of this technical note is to demonstrate the protocol for the use of PRF membranes in the secondary ABG performed at the Centro de Tratamento das Anomalias Craniofaciais - Universidade do Estado do Rio de Janeiro (CTAC-UERJ).


  Technical Note Top


Preoperative assessment

The usual clinical examination is supplemented by a complete radiological assessment including a cone beam computed tomography to estimate the position of the permanent lateral incisor, if present, or the central incisor, or the canine adjacent to the cleft, as well as assessing the size and shape of the alveolar defect. Usually, the ABG procedure is carried out after orthodontic expansion.

Platelet-rich fibrin membranes protocol

Blood samples were collected from each patient with a 21G scalp (BD, Brazil), in 10 ml glass collection tubes, without the addition of other chemicals (BD, Brazil). After collection, the blood was immediately subjected to centrifugation in a vertical rotor centrifuge (Montserrat ®, São Paulo, Brazil), with a force of approximately 400 g, for 12 min. At the end of the procedure, the clots were removed from the collection tubes and implanted directly into the operated site as barriers.[6],[7]

The membranes were produced by exerting light pressure using gauze for implantation on the surgical site.


  Surgical Technique Top


This technique is performed under general anesthesia. The patient, placed in dorsal decubitus, is intubated with an orotracheal tube.

The procedure begins with infiltration of 2% lidocaine with 1:200.000 epinephrine into both the palatal mucoperiosteum and the vestibular sulcus on both sides of the cleft.

Incision and detachment

Usually, a horizontal incision is made about 4 mm above the attached gingiva on the vestibular side, from the permanent first molar and extended medially to the oronasal fistula. In wide defects, the intrasulcular incision can be carried in the teeth adjacent to the cleft to facilitate the suture of the vestibular flap. This dissection is carried out on the inner aspect of the maxilla until expose the lateral wall of the cleft. The same incision should be performed, with less extension, on the noncleft side enough to expose the nasal floor, anterior nasal spine, and medial margin of the cleft alveolus. Finally, the borders of the fistula are excised [Figure 1].
Figure 1: (a) Schematic of incisions. (b) Schematic view after dissection of mucoperiosteal flap. Note the permanent canine with 2/3 root formed

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If the palate is open, a mucoperiosteal flap is made in the palate in both sides. The intrasulcular incision can be made from the tuberosity region until anterior hard palate. The extension of this incision varies according to the cleft pattern. A wide and careful dissection allows accurate definition of the union among nasal and palatal mucosa. In this way, the separation of anatomical units is easier.

Nasal and palatal flaps closure (key area of concern)

For a correct closure of the soft tissues, the alveolar cleft should be seen as a three-dimensional structure like a pyramid, where the base is the vestibular alveolar defect, the lateral walls represent the bone margins of the cleft, the inferior wall will be formed by the palatal mucosa and the upper wall will be formed by the nasal mucosa [Figure 2].[2]
Figure 2: Representation of the pyramid shape in the alveolar cleft. Key area of concern (apex of the pyramid). In its region, the closure may be compromised by the difficulty of access. Nasal mucosa closed with vomer flap (upper part) and mucoperiosteal flap from lateral margins of the cleft. The palatal mucosa reconstructed with vomer flap (lower part) and with the advancement of palatal flap

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The closure of the nasal mucosa is performed from the upper rotation of the vomer flap superior base, which will join with the flap of the lateral margin of the cleft to form the mucosa of the nasal floor. This is the most critical step of the entire procedure and deserves special attention. In its posterior region (apex of the pyramid), the closure may be compromised by the difficulty of access [Figure 2]. Often, it is not possible to ensure that an adequate closure of the nasal mucosa has been achieved. Failure in this step may lead to contamination with partial or total loss of the bone graft.

The palatal mucosa is reconstructed with the advancement of the palatal flap on both sides. If necessary, the lower part of the vomer flap can be used to assist in the closure [Figure 2].

Platelet-rich fibrin membrane

A PRF membrane is placed covering the suture line of the nasal and palatal mucosa [Figure 3]. This membrane has biological and physical barrier properties. In addition, the membrane accelerates healing and recovery, decreases the risk of infection and postoperative discomfort.
Figure 3: Platelet-rich fibrin membranes placed over suture line. The membrane work, such as barrier, when appropriate closure cannot be obtained

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The numbers of membranes will depend on the size of the defect usually one PRF membrane for each suture line is enough.

Bone graft

The iliac bone is the preferred donor site because it provides ample cortical and cancellous bone for even large defects. A segment of cortical bone is fashioned to fit into the roof of the pyramid. The cortical side of this bone is placed against the PRF membrane and the reconstructed nasal mucosa. It helps to sustain and reinforce the nasal floor [Figure 4]. The remaining space between the cortical bone and the palatal mucosa is packed with a cancellous bone with pressure [Figure 5]. Finally, another layer of PRF membrane is seated in frontal aspect of the defect (pyramid base), underneath the vestibular flap. In this way, the PRF membranes produce a protective layer, isolating the ABG [Figure 6].
Figure 4: Cortical bone is fashioned to fit into the roof of the pyramid. It helps to sustain and reinforce the nasal floor

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Figure 5: Cancellous bone filling in alveolar defect with pressure

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Figure 6: Platelet-rich fibrin membrane seated in frontal aspect of the defect (pyramid base). The membranes produce a protective layer, isolating the ABG

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Vestibular flap closure

The labial gingiva-periosteal flaps are closed over the anterior wall and sutured using 4-0 Vicryl to the palatal flaps to cover the tooth-erupting surface [Figure 7].
Figure 7: Closure of the flaps

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  Discussion Top


The ABG is an essential step in the overall management of a cleft lip and palate patient. Secondary ABG procedure, performed between 9 and 12 years of age, has been established as the “gold standard” for alveolar cleft reconstruction and has provided foundational support in current cleft management.[2],[8],[9] However, in our center, we adopt the method described by Precious.[1] As reported the optimum time to perform alveolar bone grafting is when the permanent lateral incisor, if present, or the central incisor adjacent to the cleft is only beginning to erupt, usually at about 5.5–6 years of age.

The main cause of failure in the ABG is the contamination of the graft after exposition in the nasal cavity.[2],[9] Due to that, some surgeons have advocated with the ABG should be delayed until stable soft-tissue coverage has been achieved. Nevertheless, in our experience, the PRF membrane protects the grafted area, even when appropriate closure cannot be obtained. Thus, another surgical procedure is avoided [Figure 8].
Figure 8: (a) Clinical case. Presurgery, oronasal fistula. (b) Nasal mucosa suture (key area), with vomer flap and mucoperiosteal flap from lateral margins of the cleft. (c) Platelet-rich fibrin membrane sutured covering nasal mucosa. (d) Cortical bone helps to sustain and reinforce the nasal floor. (e) Space between the cortical bone and the palatal mucosa is packed with cancellous bone with pressure. (f) Platelet-rich fibrin membrane covered the alveolar bone graft. (g) Labial gingiva-periosteal flap closed

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Few articles [10],[11],[12],[13] have been proposing the use of growth factors to enhance the results in ABG. These authors mix growth factors and cancellous bone to improve the osteogenic capacity of the graft. As shown in this technical note, the use of PRF membranes can improve the results of the ABG, promoting faster healing and protection of the bone graft in the case of dehiscence, acting as a physical barrier [Figure 9].
Figure 9: (a) Presurgery complete bilateral cleft lip, patient carried out the surgery as described in this technical note. (b) Postsurgery, 18-month follow-up. Note the eruption of the permanent canine in adequate alveolar ridge, with no oronasal fistula and good periodontal condition

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  Conclusion Top


In the current economic environment, in which reduced cost measures are needed, it is beneficial to perform a procedure more efficiently with a decreased complication rate. The production of PRF membranes is cheap, fast, and simple. It may contribute to a more efficient surgical procedure with a quicker convalescence for the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Precious DS. A new reliable method for alveolar bone grafting at about 6 years of age. J Oral Maxillofac Surg 2009;67:2045-53.  Back to cited text no. 1
[PUBMED]    
2.
Craven C, Cole P, Hollier L Jr., Stal S. Ensuring success in alveolar bone grafting: A three-dimensional approach. J Craniofac Surg 2007;18:855-9.  Back to cited text no. 2
    
3.
Chang HP, Chuang MC, Yang YH, Liu PH, Chang CH, Cheng CF, et al. Maxillofacial growth in children with unilateral cleft lip and palate following secondary alveolar bone grafting: An interim evaluation. Plast Reconstr Surg 2005;115:687-95.  Back to cited text no. 3
    
4.
Miron RJ, Zucchelli G, Pikos MA, Salama M, Lee S, Guillemette V, et al. Use of platelet-rich fibrin in regenerative dentistry: A systematic review. Clin Oral Investig 2017;21:1913-27.  Back to cited text no. 4
    
5.
Bayer A, Lammel J, Rademacher F, Groß J, Siggelkow M, Lippross S, et al. Platelet-released growth factors induce the antimicrobial peptide human beta-defensin-2 in primary keratinocytes. Exp Dermatol 2016;25:460-5.  Back to cited text no. 5
    
6.
Mourão CF, Valiense H, Melo ER, Mourão NB, Maia MD. Obtention of injectable platelets rich-fibrin (i-PRF) and its polymerization with bone graft: Technical note. Rev Col Bras Cir 2015;42:421-3.  Back to cited text no. 6
    
7.
Mourão CF, Mourão NB. Platelet-rich fibrin membrane in immediate loading of dental implants. Dent Press Implantol 2015;9:104-9.  Back to cited text no. 7
    
8.
Schultze-Mosgau S, Nkenke E, Schlegel AK, Hirschfelder U, Wiltfang J. Analysis of bone resorption after secondary alveolar cleft bone grafts before and after canine eruption in connection with orthodontic gap closure or prosthodontic treatment. J Oral Maxillofac Surg 2003;61:1245-8.  Back to cited text no. 8
    
9.
Coots BK. Alveolar bone grafting: Past, present, and new horizons. Semin Plast Surg 2012;26:178-83.  Back to cited text no. 9
    
10.
González-Sánchez JG, Jiménez-Barragán K. Closure of recurrent cleft palate fistulas with plasma rich in growth factors. Acta Otorrinolaringol Esp 2011;62:448-53.  Back to cited text no. 10
    
11.
Oyama T, Nishimoto S, Tsugawa T, Shimizu F. Efficacy of platelet-rich plasma in alveolar bone grafting. J Oral Maxillofac Surg 2004;62:555-8.  Back to cited text no. 11
    
12.
Marukawa E, Oshina H, Iino G, Morita K, Omura K. Reduction of bone resorption by the application of platelet-rich plasma (PRP) in bone grafting of the alveolar cleft. J Craniomaxillofac Surg 2011;39:278-83.  Back to cited text no. 12
    
13.
Nadon F, Chaput B, Périssé J, de Bérail A, Lauwers F, Lopez R, et al. Interest of mineralized plasmatic matrix in secondary autogenous bone graft for the treatment of alveolar clefts. J Craniofac Surg 2015;26:2148-51.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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Abstract
Introduction
Technical Note
Surgical Technique
Discussion
Conclusion
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