Ask The Doctor: Bone & Gingival Graft with a Periodontist

Earl Gage, MD

Kids Plastic Surgery, Mercy Children’s Hospital – St Louis, MO

Question: Our child is being referred to a Periodontist for a second bone graft and gingival graft for the upper front teeth. We have been told this is a more delicate surgery than the initial bone graft that the plastic surgeon performed 2 years ago. What kind of questions should we ask about the surgery and determining which doctor to use?

Answer: Thanks for your question. I presume from your question that your child had a cleft lip and palate and that the graft 2 years ago was to close the cleft in the alveolus or gum line. There are certainly times when re-grafting is necessary. Sometimes the first graft fails. Sometimes the graft “takes” but there is insufficient bone to allow a subsequent desired procedure, such as placement of a permanent dental implant. More often than not, the re-grafting procedure is essentially the same as the first surgery. With any bone graft surgery, it is critical that there be healthy soft tissue to cover and protect the graft as it integrates. Ideally, we want a water-tight seal around the graft. If the incision pulls apart or if there is a persistent open connection from the nose or the mouth into the space where the graft was placed, the graft is likely to become infected and fail.

Since children with craniofacial and cleft problems are more complex to manage than children without these types of diagnoses, I would first recommend that you ask your periodontist if he or she has experience in doing these types of procedures in kids with similar diagnoses. Experience and judgment matter. Secondly, I would be a little nervous about bone grafting and gingival grafting being done at the same time if the gingival grafting procedure will result in other incisions and soft tissue disruption near the site of bone grafting. Again, you want healthy soft tissue and a water-tight seal. Anything that may compromise this type of closure needs to be carefully discussed. I would spend some time talking to your periodontist about what’s involved with gingival grafting and whether it may put the bone graft at risk. Finally, once you meet with the periodontist, I would recommend you discuss the plan with your craniofacial surgeon to make sure they feel it is safe and makes sense.

Best of luck!

Ask the Doctor: Positional Plagiocephaly

We have been working with the team at Texas Children's Hospital to bring you some FAQs as part of our effort to provide relevant, timely, and much-needed medical information to you.  We believe that helping patients and their families find and access the right craniofacial team is an essential service that we provide. Today's FAQs concern babies with plagiocephaly who wear a helmet.

From the doctor:
Our patient families have helped generate Frequently Asked Questions about cranial orthotic helmets. Some babies are in helmets for positional plagiocephaly, while others are in helmets after endoscopic craniosynostosis surgery. We prepared some typical answers to helmet FAQ's. Many families have worked with Jim Brookshier CPO LPO (orthotist), who has been taking care of children's helmet and head shape needs in Texas for over 10 years. Jim has partnered up with me to write these FAQ sheets. Of course, this information cannot substitute for regular visits with your orthotist and your physician to avoid problems and to work towards the best outcomes possible.

Sandi Lam MD MBA
Pediatric Neurosurgeon
Texas Children's Hospital Craniofacial Surgery Team

See the PDF here.

Texas Children's shares Craniosynostosis Helmet FAQs

Today on the blog, we are expanding our "Ask the Doctor" series!

We have been working with the team at Texas Children's Hospital to bring you some FAQs as part of our effort to provide relevant, timely, and much-needed medical information to you.  We believe that helping patients and their families find and access the right craniofacial team is an essential service that we provide. Today's FAQs concern babies who wear helmets after craniosynostosis surgery and next week, we'll post the FAQs for plagiocephaly helmet wear.

From the doctor:
Our patient families have helped generate Frequently Asked Questions about cranial orthotic helmets. Some babies are in helmets for positional plagiocephaly, while others are in helmets after endoscopic craniosynostosis surgery. We prepared some typical answers to helmet FAQ's. Many families have worked with Jim Brookshier CPO LPO (orthotist), who has been taking care of children's helmet and head shape needs in Texas for over 10 years. Jim has partnered up with me to write these FAQ sheets. Of course, this information cannot substitute for regular visits with your orthotist and your physician to avoid problems and to work towards the best outcomes possible.

Sandi Lam MD MBA
Pediatric Neurosurgeon
Texas Children's Hospital Craniofacial Surgery Team

See the PDF here.

Ask The Doctor: Can Craniosynostosis be detected prenatally?

By Earl Gage, MD 

Kids Plastic Surgery, Mercy Children’s Hospital – St Louis, MO

Question: Can Craniosynostosis be detected prenatally? I am a 61 year old mom who gave birth to a daughter in 1991 with craniosynostosis and would like to let her know this answer when the time comes for her to get married and start her own family.

Answer:  Thanks for your question. In short, I would say that detection of craniosynostosis by prenatal ultrasound is difficult. This is partially due to the difficulty in getting a “clear look” at the sutures  (or skull expansion joints) when the baby is active and moving in the womb. In addition, prior to birth, the skull bones are not fully developed and have not calcified completely. This can make it more difficult to see the sutures and determine if the bone is fused. In fact, I can think of instances where a newborn child clinically appeared to have craniosynostosis but an early skull xray or ultrasound, obtained by a pediatrician, seemed to show the suture was “open.” In essence, the child had craniosynostosis and a non-functioning suture, but the suture hadn’t calcified sufficiently to make fusion detectable by imaging.  For these reasons, I prefer to rely on a good clinical exam of a newborn infant rather than on ultrasounds or xrays done before birth or even in the first days of life.
While definitive diagnosis of craniosynostosis is difficult prior to birth, there are instances when craniosynostosis is suspected prenatally based on abnormal head shape as detected by ultrasound. For instance, when a child has sagittal synostosis, the skull becomes elongated front-to-back and sometimes tapers posteriorly. This characteristic shape may be seen on ultrasound. Similarly, with some types of syndromic craniosynostosis (eg Pfeiffer syndrome), a markedly abnormal “clover leaf skull” deformity may be present, and this can be detected by ultrasound, too. A diagnosis of craniosynostosis can even be suspected based on the occurrence of other associated abnormalities picked-up on ultrasound, such as fused fingers and toes as seen in Apert syndrome, a condition frequently associated with bicoronal craniosynostosis. However, since abnormal skull shapes due to craniosynostosis are usually mild prenatally (and even at birth) and since head shapes tend to get progressively worse over time, prenatal head shape findings can be subtle and are not always obvious. For this reason, it is most likely that ultrasound detection of abnormal head shape suggestive of craniosynostosis may not be possible until later in pregnancy.
When a diagnosis of craniosynostosis is suspected based on head shape or based on other abnormal findings with the unborn baby, I would encourage the family to meet with a craniofacial surgeon and discuss the possible diagnosis and what may be involved in future care. Ask a lot of questions and do some research before things get really busy with the baby’s arrival. Once the baby arrives, diagnosis of craniosynostosis may just require a physical exam, but additional imaging with a CT scan or MRI may be suggested by your team.

Ask the Doctor: Options for Teen's Forehead

CCA posts a monthly blog series called, "Ask the Doctor." You can submit your questions to Annie Reeves ([email protected]) and we will ask Dr. Earl Gage of Kids' Plastic Surgery in St. Louis to answer them. Thanks Dr. Gage for helping spread information and resources for our cranio families!

Ask the Doctor

Earl Gage, MD, Kids Plastic Surgery, MercyChildren’s Hospital
Ask The Doctor

Earl Gage, MD

Kids Plastic Surgery, Mercy Children’s Hospital – St Louis, MO

Question: My daughter had bicoronal craniosynostosis (no known syndromes) corrected at 3 mos of age. She has no protruding brow bone over the eye, and where her eyebrows lie is very tight almost like a band is constructing that part of her forehead. Her surgeons from UC Davis have moved out of state, so we have not had follow up in many years. She is currently 15. Is there anything we can do to normalize this area of her face? The concern is primarily cosmetic, although her eyes are at risk without the normal brow bone protection. Is dermal filler an option? What kind of doctor should we see?

Answer:  The problem that you describe sounds like the orbital rim and forehead sit too far back. This can be a result of inadequate advancement at the time of the original surgery. It can just as easily be the result of regression or relapse following a well-done procedure, especially if the soft tissue was tight following an aggressive advancement.

Most of the time, when the brow and forehead sit too far back and the eyes are exposed, surgical correction by re-advancement of the forehead and brow are needed to normalize appearance and protect the eyes. Most of the time, this can be accomplished by doing a similar surgery to the one she had in infancy. The tightness of the skin may pose some challenges in moving the forehead forward, but this is usually manageable.

There are other options that can camouflage problems with forehead shape and position, such as prosthetic custom implants, dermal fillers or fat grafting. With custom implants, however, you need to have soft, healthy soft tissue in the area in order to minimize risk of implant complications or implant exposure. When the skin is scarred and tight, the risk in placing an implant may be too high. With dermal fillers and fat grafting, you should not expect to have dramatic changes. These modalities are really best when trying to smooth or improve small contour irregularities.

I cannot give you a specific recommendation for your daughter since I have not seen her and do not have a clear picture of her forehead position or the soft tissue challenges that may be present. However, based on your description, it sounds like surgery may be required to get the improvement she wants. You should see a craniofacial plastic surgeon in your area to get an in-person assessment and come up with a personalized plan for your daughter.

Ask the Doctor: Why do you leave distraction device on so long?

CCA posts a monthly blog series called, "Ask the Doctor." You can submit your questions to Annie Reeves ([email protected]) and we will ask Dr. Earl Gage of Kids' Plastic Surgery in St. Louis to answer them. Thanks Dr. Gage for helping spread information and resources for our cranio families!

Ask the Doctor

Earl Gage, MD, Kids Plastic Surgery, MercyChildren’s Hospital
Ask The Doctor

Earl Gage, MD

Kids Plastic Surgery, Mercy Children’s Hospital – St Louis, MO

Question: My five year son had his frontal advancement procedure done one month ago. The doctor told us that it would take about two months for the halo to complete the process. Last week the doctor then made the decision to remove the halo because some of the hardware had loosened, a cord was damaged and one of the sites was getting infected.  He said the advancement was already done anyway. My question is if the halo completes its job when it doesn't need turning anymore why do they leave it on for such of long time?

Answer:  Distraction osteogenesis involves cutting a bone and then slowly lengthening the bone by applying a constant steady force. In order to understand the phases of distraction and why we leave the halo on even after the work of moving the bone is done, it helps to first understand what happens when a bone is broken and needs to heal.

When a bone is fractured, the body begins the healing process by stimulating cartilage and bone producing cells at both ends of the fracture to begin laying down new hyaline cartilage and woven bone in an effort to bridge the fracture gap. This new tissue spanning the fracture is called a callus and is relatively soft. Once the gap is bridged, the callus tissue is eventually replaced with stronger lamellar bone. Additional biologic changes and modifications of the bone occur until complete healing is accomplished. During the process of fracture healing, it is necessary to have good blood supply, good nutrition, good alignment of the fracture edges and good bone immobilization. Fracture healing often takes 4-6 weeks or longer.

Beginning in the early 1900’s some physicians realized that bone could be lengthened applying tension to the bone while in the callus phase of healing. If you lengthen the bone at just the right rate, you can continue to lengthen the bone at the callus while new bone is being formed just behind the callus.  In essence you stay just ahead of where the bone is becoming solid and stretch the soft stuff.

Once you have achieved your bone-lengthening goal, you then stop applying the lengthening force to the bone and instead try to provide stability and immobilization of the fracture so that bone healing catches up and the bone becomes strong. 

The reason, therefore, that there is a period of time after you are done turning the screws is to provide stability to the bones while the bone healing “catches up” and makes the bone solid and strong. This is called the consolidation phase of distraction and may take 4-6 weeks to allow full healing to occur. If the distractor is removed too early, while the bone is still healing and relatively soft, then there is a risk that you could lose some of your gains or that the fracture may not heal appropriately. 

Although we all want to have the distractor in place through consolidation, there are times when the distractor mechanism needs to be removed early. Reasons for early removal can include infection, malfunction or accidental dislodgement. Depending on when this occurs in the process of distraction and consolidation, the surgeon then has to make a judgment whether the bone is sufficiently solid to allow removal or if something else needs to be done to provide stability while the fracture continues to heal. A decision to put a new halo on is a decision based on risks and benefits of another surgery. From what you describe, it sounds as though your surgeon felt that things would be sufficiently stable to allow early removal.

I hope this helps answer your question, and I hope your son recovers well from his surgery.