Interdisciplinary approach for a patient with unilateral cleft lip and palate

A meta-analysis of alveolar bone grafting using bone substitutes in cleft lip and palate patients

In individuals with cleft lip and palate (CLP), an alveolar bone graft (ABG) is carried out for alveolar cleft closure. Several sources for ABG include autologous bone, xenologous bone, and alloplastic substitutes. Autologous bone has been the preferred source for ABG. Alloplastic substitutes might serve as an alternative. This study aimed to compare the outcomes between autologous and alloplastic as sources for ABG. This study made use of eight web databases. Randomized control trials (RCTs) and non-RCTs were included. CLP patients with alveolar cleft with imaging studies, computed tomography (CT scan) and/or cone beam CT scan, and bone graft volume within 6-12 months postintervention were selected. Bone graft volume within 6-12 months postintervention was assessed. Three studies met the inclusion criteria. After 6-12 months of follow-up, there were no statistically significant differences in bone graft volume between autologous and alloplastic bone grafts (fixed-effect model estimate value = 0.21; confidence interval - 0.301-0.730; P = 0.414). The limitations include small research sample sizes, a high likelihood of bias among included studies, and different alloplastic materials from each included study. Autologous and alloplastic bone grafts showed similar effectiveness in alveolar bone grafting. Further clinical trial studies with bigger sample sizes and similar interventions are needed as evidence for future reviews.

Comparative study of the anaesthetic efficacy of 4% articaine versus 2% mepivacaine in mandibular third molar germectomy using different anaesthetic techniques: a split-mouth clinical trial

BACKGROUND

Currently, one of the most discouraging aspects for many patients undergoing dental procedures is the administration of local anaesthesia. Therefore, there is a constant search for new techniques to avoid the invasive and painful nature of the injection. This study aimed to compare the clinical efficacy of local anaesthetics with articaine 4% or mepivacaine 2% (both with epinephrine 1:100.000), using different anaesthetic techniques to perform germectomy of lower third molars and to assess patients' feelings and pain during surgery.

METHODS

Totally 50 patients (ranged 11-16 years) who required germectomy of mandibular third molars were recruited. Each patient received local anaesthesia on one side with articaine inoculated with plexus technique while on the other side with mepivacaine using inferior alveolar nerve block technique. The patients' evaluation was performed on pre and intraoperative tactile-pressure feelings and intraoperative pain with four levels on the Visual Analogue Scale (VAS).

RESULTS

Surgical operations lasted less with more efficient analgesia when articaine was used. The additional intraosseous injection was required mainly in the mepivacaine group intraoperatively. A few patients had tactile-pressure feelings while intraoperative pain sensation was absent in 90% of cases with articaine. Significant differences were found in the cases who reported "absent" and "moderate" VAS values, favoring the use of articaine.

CONCLUSIONS

Articaine injected with a plexus anaesthetic technique seems to be more clinically manageable than mepivacaine for the mandibular third molar germectomy. The discomfort of tactile-pressure feelings and pain experienced was lower using articaine anaesthetic technique used.

Impact of a new combined preoperative cleft assessment on dental implant success in patients with cleft and palate: a retrospective study

Background

Bone height assessment alone is frequently used to guide rehabilitation choice, without consideration for soft tissues or adjacent teeth. This study aimed to evaluate the impact of different preoperative cleft assessments on implant success and patient satisfaction.

Methods

The study involved a retrospective assessment of records from 40 patients with cleft lip and palate (CLP). The alveolar cleft score (ACS; clinical criteria), interdental alveolar bone height (IABH) score (radiological criteria), patient compliance score (dental hygiene, medical visit observance, and smoking), and a novel combined score (IABH-ACS-Compliance) were assessed from patient records. Patients who required prosthetic tooth rehabilitation in the cleft dental arch space were included. Twenty-six patients (Group 1) were treated with dental implants, and 14 patients (Group 2) selected another prosthetic option (fixed prosthodontics, removal prosthesis), orthodontic space closure, or no rehabilitation. The main outcomes measured were relative implant success (no implant loss involving marginal bone loss ≤ 1.9 mm) for patients treated with dental implant therapy (Group 1) and patient satisfaction for all patients (Groups 1 and 2).

Results

Forty dental implants were placed in the patients in Group 1. Four implants in four patients (Group 1 relative failure, RF) were lost (implant survival rate of 90%) after 36 (± 12.4) months of follow-up. Twenty-two patients who received implants belonged to the relative implant success group (Group 1 RS). The average “IABH-ACS-Compliance” scores were significantly different (p < 0.05): 16.90 ± 2.35 and 12.75 ± 0.43 for the Group 1 RS and RF groups, respectively.

Conclusions

Preoperative cleft parameters have an impact on relative implant success and patient satisfaction. The new cleft assessment combined-score (“IABH-ACS-Compliance”) allows an accurate selection of cleft cases eligible for dental implants, thereby improving postoperative outcomes.

The circadian clock component BMAL1 regulates osteogenesis in osseointegration

Congenital and developmental craniofacial deformities often cause bone defects, misalignment, and soft tissue asymmetry, which can lead to facial function and morphologic abnormalities, especially among children born with cleft lip and palate. Joint efforts from oral maxillofacial surgery, oral implantology, and cosmetic surgery are often required for diagnosis and treatment. As one of the most widely performed treatment methods, implant-supported cranio-maxillofacial prostheses have been widely applied in the course of treatment. Therefore, stability of peri-implant bone tissue is crucial for the long-term success of treatment and patients' quality of life. The circadian clock component brain and muscle aryl hydrocarbon receptor nuclear translocator-like protein 1 (BMAL1) was found to be involved in the cell fate of bone marrow mesenchymal stem cells, which were essential in the fixation of titanium implants. This study aimed to investigate the effect of BMAL1 on osteogenesis in osseointegration, providing a brand new solution to increase bone implant conjunction efficiency and implant stability, paving the way for a long-term satisfactory therapy outcome.

Emergence agitation after the cleft lip or palate surgery in pediatric patients: a prospective study

OBJECTIVE

The pediatric patients after the cleft lip or palate surgery have high incidences of postoperative complications. Emergence agitation is a common complication. It is also a mild complication compared with lingual swelling and other airway-related complications, which are more often expected in children. However, it can cover signs of hypoxic episodes that appear immediately after surgery, because enough monitoring of an agitated child is not possible. The study aimed to discuss the occurrence of EA after cleft lip or palate surgery in pediatric patients, and further to provide a basis for later interventions.

METHODS

This prospective study included 214 patients aged 3 months to 6 years old at a tertiary stomatological teaching hospital. We calculated the EA scores for every patient when they entered PACU, were in PACU, and left from PACU, and the score ranges from 1 to 5 point. The patients occurred agitation if they scored from 3 to 5 on the 5-point scale, and the patients needed medication and care if they had a score of 4 or 5.

RESULT

The results showed that the EA scores of 69.63% (n = 149) among patients were 3 or higher when they entered PACU, 40.65% (n = 87) were 3 or higher when they were in PACU, and 21.03% (n = 45) were 3 or higher when they left from PACU. Whether they are children with cleft lip, cleft palate, or horizontal cleft, the EA scores had a significant difference among different timings when entering PACU, in PACU, and leaving PACU (P = 0.000). Further comparison showed that the EA score of patients was the highest when entering PACU, and the lowest when leaving PACU. A significant difference in the EA scores was found among the patients with cleft lip, cleft palate, and horizontal cleft when they were in PACU (P = 0.024), further comparison showed that the EA score of the patients with cleft lip was lower than patients with cleft palate or horizontal cleft. While there were no statistical differences in the EA scores among the patients with cleft lip, cleft palate, and horizontal cleft when they entered PACU and left from PACU (P > 0.05).

CONCLUSION

Children had a high incidence of EA after cleft lip or cleft palate or horizontal cleft surgery, especially when they entered PACU. Children after cleft palate and horizontal cleft surgery had higher incidences of EA than cleft lip surgery when they were in PACU.

Orthodontic treatment of unilateral cleft lip and palate associated with maxillary canine/premolar transposition: case report

Introduction:

The cleft lip and palate is the most frequent craniofacial anomaly and as a consequence of this malformation some inadequate occlusal relationship between the arches are observed. Furthermore, dental absences, individual positioning changes of teeth as rotations, and in more rare situations the transpositions may be found as well.

Description:

In this context, in this article is reported a case of a 9-year-old patient with unilateral cleft lip and palate, with anterior and posterior crossbite on the left side, absence of the maxillary left lateral incisor, and transposition of the maxillary left canine and first premolar. The patient was treated with slow maxillary expansion, secondary graft and fixed orthodontic appliance, transposition maintenance and closing of the lateral incisor space with the first premolar, by means of mesialization of the posterior teeth.

Results:

At the end of the treatment, good intercuspation and an important aesthetic gain for the patient were achieved. The analysis three years after treatment revealed a good stability of the results obtained.

Secondary alveolar bone grafting using autologous versus alloplastic material in the treatment of cleft lip and palate patients: systematic review and meta-analysis

Background

A systematic review assessing autologous versus alloplastic bone for secondary alveolar bone grafting in patients with cleft lip and palate was published in 2011 and included only one randomized controlled trial comparing traditional iliac bone graft to recombinant human bone morphogenetic protein-2 (rh-BMP2).

Objectives

To perform a systematic review with meta-analysis on the use of secondary alveolar bone grafting (autologous bone and rh-BMP2 graft) in order to improve bone volume and height in patients with cleft lip and palate.

Data sources

An electronic search was conducted via PubMed/MEDLINE, Cochrane Central Register of Controlled Trials (CONTROL) via Cochrane Library, EMBASE via Ovid, and LILAC for studies published between January 2008 and September 2018. The systematic review registration number at PROSPERO was 42018085858.

Eligibility criteria

Only RCTs were included. Inclusion criteria were patients with the diagnosis of unilateral cleft lip and palate older than 5 years of age, radiographic evaluation (CT and/or CBCT) of the cleft area, and at least a 6-month follow-up.

Main outcome measures

Bone formation and bone height by radiographic CT evaluation (preoperatively, after 6 months and after 1 year of follow-up) and length of hospital stay were assessed.

Results

Four studies met strict inclusion criteria. Autologous bone graft showed statistically significant higher bone formation after 6-month follow-up (MD − 14.410; 95% CI − 22.392 to − 6.428; p = 0.000). No statistically significant difference was noted after a 1-year follow-up (MD 6.227; 95% CI − 15.967 to 28.422; p = 0.582). No statistically significant difference in bone height was noted after 6-month (MD − 18.737; 95% CI − 43.560 to 6.087; p = 0.139) and 1-year follow-up (MD − 4.401; 95% CI − 30.636 to 21.834; p = 0.742). Patients who underwent rh-BMP2 graft had a statistically significant reduced hospital stay (MD − 1.146; 95% CI − 2.147 to − 0.145; p = 0.025).

Limitations

The main limitation is the high risk of bias among included studies.

Conclusion

Autologous bone and rh-BMP2 graft showed a similar effectiveness in maxillary alveolar reconstruction in patients with unilateral cleft lip and palate assessing bone graft volume and height although rh-BMP2 graft showed a relative shorter length of hospital stay (high uncertainty level).

Electronic supplementary material

The online version of this article (10.1186/s40510-018-0252-y) contains supplementary material, which is available to authorized users.

Three-Dimensional Soft-Tissue Evaluation in Patients with Cleft Lip and Palate

BACKGROUND In cleft lip and palate (CLP) patients, the shape of the facial soft tissues shows variety in 3 dimensions (3D). Two-dimensional (2D) photographs and radiographs are insufficient in the examination of these anomalies. The aim of this retrospective study was to examine the soft tissue and craniofacial characteristics of individuals with nonsyndromic unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), skeletal Class III malocclusions, or skeletal Class I malocclusions using 3D facial imaging. MATERIAL AND METHODS The entire study group consisted of a total of 158 patients, aged 8-32 years: 29 of the patients had UCLP, 22 BCLP, 54 had skeletal Class III malocclusions, and 53 had skeletal Class I malocclusions. 3D stereophotogrammetric soft-tissue recordings of all patients were analyzed. ANOVA and the Kruskal-Wallis test were performed to compare the groups. RESULTS Statistically significant differences were observed among the groups in terms of linear, angular, proportional. and volumetric measurements. While nasal differences were not observed in the Class III group, nose and upper-lip deformities were common in the CLP groups. Upper-lip projection was reduced in all 3 groups. In the Class III patients, the lower lip and chin were more prominent than in the other groups. The facial convexity angle was increased in the CLP and Class III groups. The upper-lip volume was decreased in the BCLP, the UCLP, and the Class III groups. CONCLUSIONS Patients with skeletal Class III or CLP anomalies showed significantly different soft-tissue characteristics than the Class I control group. 3D stereophotogrammetric facial imaging is an easy and noninvasive method that can be used in examination and recording of these facial deformities. It is possible to make volumetric measurements using this method.