Tc-diphosphonates bone scintigraphy for vitality evaluation in cleft palate - PDF Document

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  1. European Review for Medical and Pharmacological Sciences 2018; 22: 8497-8501 99mTc-diphosphonates bone scintigraphy for vitality evaluation in cleft palate A. BALLINI1, S. CANTORE1, C. ALTINI2, G. DIPALMA3, C. FERRARI2, A. NICCOLI ASABELLA2, G. RUBINI2, F. INCHINGOLO3 1Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy 2Department of Interdisciplinary Medicine, Nuclear Medicine Unit, University of Bari Aldo Moro, Bari, Italy 3Department of Interdisciplinary Medicine, University of Bari Aldo Moro, Bari, Italy Andrea Ballini, Stefania Cantore and Corinna Altini contributed equally to this work Abstract.–Cleft of the lip, palate and alve- olus are congenital oro-maxillofacial malforma- tion with an established treatment protocol. At present, there is great interest in the alveolar bone grafting procedures that involve the use of platelet-rich-plasma (PRP), to enhance bone for- mation and specifically to promote bone graft healing in head and neck tissues regeneration. The aim of this retrospective case report study was to assess the condition and viability of the standard bone grafting in association with PRP (platelet rich plasma) to enhance osteogenesis and maintain osteointegration in alveolar cleft with a follow up of eight years from the surgi- cal procedure. The viability of bone grafts was documented by means of head bone scintigra- phy (99mTc-MDP). The scintigrams revealed the decreased uptake at the cleft region and the in- creased uptake at the adjacent alveolus of the cleft. From these findings we suggest that plate- let concentrates decrease the need of further surgical intervention in cleft palate patients. In addition, scintigraphy may be useful to evalu- ate postoperative bone formation in the alveo- lar cleft. principal concern in cleft palate repair is closure of the physical defect, with the best velopharyn- geal (VP) function and perfect speech, without affecting the maxillofacial growth or hearing3-5. Velopharyngeal insufficiency and oronasal fistu- la represent the most common complication after cleft palate repair5,6. Platelet rich plasma (PRP) is an autologous platelet concentrate which con- tains several growth factors that are useful for enhancing wound healing and bone regeneration in surgical procedures7,8. The main uses of PRP to date are in head tissues regeneration, especial- ly in dental and maxillofacial surgery, to repair defects caused by dental extraction, or tumor resection, as well as for alveoloplasty, and has proven successful outcomes when used in com- bination with bone curettage in the treatment of refractory bisphosphonate-related osteonecrosis of the jaw9-11. Other specialties have investigated its effect in surgical procedures such as acro- mioplasty, arthroscopy, rhytidectomy with fat grafts, skin wounds and infiltration due to an- kle ligament injury9. Surgical techniques, their variations, and the outcome and rehabilitation procedures for cleft palate are constantly evolv- ing, and are very well described in the available literature12, since, in the recent years, there is an increasing of studies regarding the use of platelet concentrates and growth factors, such as PRP, in the surgical management of the cleft palate13,14. The clinically successful incorpora- tion of a graft depends on a biologic complex process, including sufficient blood supply and vitality of osteoblasts15,16. Several methods17,18 have been described to monitor the vascular status of the graft, as well the clinical evalua- Key Words: Cleft palate, Bone scintigraphy, Platelet-rich plasma (PRP), Bone grafting, 99mTc-MDP. Introduction Clefts of the lip, palate and alveolus are the commonest congenital anomaly to affect the oro-maxillofacial facial region, who occurs in about one in 700 live births worldwide, for which efforts have been made to classify and repair, since the time of Veau (1931)1,2. The 8497 Corresponding Author: Francesco Inchingolo, MD; e-mail:

  2. A. Ballini, S. Cantore, C. Altini, G. Dipalma, C. Ferrari, A. Niccoli Asabella, G. Rubini, F. Inchingolo tion of graft healing is highly subjective, many diagnostic techniques are used, including bone scintigraphy. Although radiological evaluations can reveal changes in bone density, they can- not provide information regarding osteogenesis and progression18. Nuclear medicine procedures allow the study of physiological and pathophys- iological pathways and provide functional imag- es. Biological or pathological processes can be studied depending by the radiopharmaceutical administered and current technologies allow to obtain images with high resolution and which greatly increase the accuracy of each diagnostic procedure19-21. We describe a patient who has been treated with autologous bone grafting with PRP and, at our knowledge, for the first time in literature, investigated with skeletal scintigra- phy with 99mTc-methylen-diphosphonates (99mTc- MDP) in order to have information on the long- time outcome of the treatment. ki and written informed consent was obtained from patient parents. Secondary alveolar bone grafting, according to Giudice et al22 was per- formed using the standard surgical methodology for secondary alveolar bone grafting, in addition to PRP. PRP was prepared from whole blood that was drawn into a closed system with the addition of citrate and the sampling kit was processed by an automatic biochemical system. The PRP produced was in liquid form and mixed with a solution at pH10 for being sprayed by a spray-pen during the surgical technique of bone grafting22. 99mTc-MDP bone scintigraphy was performed be- fore the treatment and repeated after 6 months from the bone grafting and then after 8 years (Figure 1 A-C). All the exams were performed two hours after the intravenous administration of 99mTc- MDP with different doses according to the age and weigh of the patients23. Tomographic (Single Photon Emission Tomography, SPECT) images were acquired with a SPECT/CT camera GE Discovery 670 dual-headed (GE Healthcare, Haifa, Israel) using a specific protocol (ener- gy window 120-140 keV, high-resolution paral- lel-hole collimators, 128 × 128 matrix size, 360° Case Study This study was carried on a single pediatric patient (9 y.o. of age) suffering from complete cleft palate with a follow up after 8 years from the surgical procedure. This study was conduct- ed in accordance with the Declaration of Helsin- Figure 1.(A) Coronal images of the SPECT bone scintigraphy performed before treatment show an area of lack uptake of 99mTc-MDP along the midline of the maxillary bone (red arrow). (B) Coronal images of bone scintigraphy performed 6 months after the treatment show intense uptake of 99mTc-MDP in the same previously missing site (red arrow). (C) The Coronal images 8 years after the surgical procedure show the homogeneous distribution of 99mTc-MDP in the maxillary bone. 8498

  3. 99mTc-diphosphonates bone scintigraphy for vitality evaluation in cleft palate acquisition, scan mode step and shoot 10 s, view angle 3°, 120 views). The projection images were iteratively reconstructed using a Gaussian filter. Coronal, sagittal and transaxial slices of the mandibular tomograms were thus generated and analyzed. Images before treatment showed the lack of 99mTc-MDP uptake in the median line of the maxillary bone, in correspondence with the congenital malformation (Figure 1 A). Instead, the images performed 6 months after the treatment showed an intense 99mTc-MDP up- take in the same site, that is, exactly the site of the bone-grafting procedure (Figure 1 B). The follow-up images showed homogeneous 99mTc- MDP uptake in all the maxillary bone, demon- strating the perfect integration of the new tissue with the native bone (Figure 1 C). and posterior to the area of interest. Therefore, the anatomic description of the process is better, which is particularly important in the mandible with its complicated 3-D structure. 99mTc-MPD SPECT scanning of the head and neck area, is useful to assess microvascular success or failure and allows a better description of the bone graft without any superimposing effects and with no additional radiation burden to the patient; in addition, the follow-up investigations can assess treatment results far better17,27-29. Conclusions The case described here shows that PRP mixed with autologous bone graft seems to be an effec- tive, safe and low-cost technique for the surgical management of cleft palate. In fact, usage of autologous PRP in complete cleft palate repair is simple and effective. Furthermore, it can de- crease the occurrence of oronasal fistula and also significantly improves the grade of nasality and velopharyngeal closure, decreasing the need for further surgical intervention in cleft palate patients. Bone scintigraphy performed within a short and long follow-up after the cleft palate reconstruction is a useful tool to monitor the viability and early complications of vascularized mandibular bone grafts and allow the long-time assessment. SPECT is strongly recommended be- cause contribute to the interpretation of the bone scans and to precise assessment of graft viability. However, there is a need for similar prospective studies to investigate the long-term effectiveness of the proposed procedure. Discussion The conventional time for secondary alveolar cleft repair is between 6 and 12 years22,24. The success of the reconstruction of the alveolar cleft is determined by the amount of bone formation in the cleft, bone height of the alveolar ridge and the position of the bone in the cleft; besides healing using PRP in our study was similar to other reported worldwide researches13,22,24,25. Bone growth problems can be analyzed with 99mTc-MPD. Bone scintigraphy with radioactive tracers has found widespread use in the imaging of bone blood flow and metabolism. 99mTc-di- phosphonates are highly sensitive for blood flow and metabolic activity of bone tissue17. In bone scintigraphy, the uptake of the radiopharma- ceutical depends both on an adequate delivery system and on a living network of osteocytes. Bone scintigraphy is an easy, non-invasive and effective modality in the assessment of post- operative graft viability26. Single photon emis- sion computed tomography (SPECT) should be favored rather than conventional planar scan- ning, because of the complex anatomy of the cranio-maxillofacial region. SPECT reconstruc- tion in bone scintigraphy was found to be an excellent tool in diagnosis and follow-up of the cranio-maxillofacial bony structures, as it is widely used to assess bone graft viability in mandibular reconstruction17,18. The major ad- vantage of conventional SPECT over planar imaging is the improvement in lesion contrast by enhancing the signal-to-noise ratio by re- moval of superimposed activity, both anterior Conflict of Interest The Authors declare that they have no conflict of interests. Authors’ Contribution G.D. and C.F. gave a scientific contribution for data inter- pretation; A.C wrote the first draft of the manuscript and su- pervised diagnostic imaging procedure; A.B. conceived the study and contributed to the study design, data analysis and interpretation, and manuscript revision; S.C. was responsi- ble for bibliographic research, patient management and da- ta collection; N.A.A. coordinate the research; F.I. and G.R. made substantial contributions to the conception and de- sign of the study, diagnosis and coordination, supervised the manuscript and gave final approval of the version to be published. All the authors have read and approved the fi- nal manuscript. 8499

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