Secondary bone grafting of alveolar clefts: a review of outcome at two centres in Australia and the UK

What is the Success Rate of Repeat Alveolar Bone Graft?

BACKGROUND

Success rates for alveolar bone grafting range from 30 to 96%. There is limited information regarding the success of repeat grafts.

PURPOSE

The purpose of this study was to determine the radiographic success rate of repeat alveolar bone grafts.

STUDY DESIGN

The study designs was a retrospective cohort study of patients who underwent repeat grafting by 1 surgeon over 15 years. To be included, subjects had to have: cleft lip and alveolus and a cone-beam computed tomography (CBCT) scan obtained >6 months after repeat graft. Patients were excluded if CBCT was inadequate.

PREDICTOR VARIABLE

Predictor variables were sex, age at repeat graft, cleft type, presence of an erupted canine, premaxillary osteotomy at time of repeat graft, presence of a visible oronasal fistula, size of bony defect, presence of a bony palatal bridge, and whether the surgeon who performed the repeat graft also performed the initial graft.

MAIN OUTCOME VARIABLE

The outcome variable was graft success determined using CBCT assessment and defined as a score of >3 out of 4 in each domain: vertical bone level, labiopalatal thickness, and piriform symmetry.

COVARIATES

The covariates were time from bone graft to CBCT (months) and age at time of CBCT (years).

ANALYSES

Frequency distributions, relative risk with 95% confidence intervals, medians, and interquartile ranges were calculated. Pearson c2 and Fisher exact tests were performed to determine predictors of outcome. A P < .05 was considered statistically significant.

RESULTS

Fifty subjects (54% male) who had repeat bone grafting to 59 cleft sites were included. Median follow-up time from repeat graft to CBCT was 7.0 months (interquartile range: 5.9 months). The radiographic success rate was 81.4%:91.7% if the same surgeon performed both initial and repeat grafts, but 78.7% if initial graft was completed by another surgeon (P = .43).

CONCLUSION AND RELEVANCE

Despite being a multifactorial issue, extensive and bilateral clefts, the presence of an erupted tooth in the cleft area, a visible oronasal fistula, and concomitant osteotomy of the premaxilla are warning signs of the possibility of failure. Performing repeat alveolar bone grafting by an experienced surgeon appears to increase the chance of success.

Bioglass 45S5, a relevant alternative to autogenous harvesting for secondary alveolar bone grafts in clefts? Retrospective study of one hundred surgeries

The secondary alveolar bone grafting (SABG) step restores the continuity of the alveolar bone necessary for dentition. Faced with the complications of autografts, synthetic biomaterials such as Bioglass (BG) 45S5 have been proposed. The objective was to evaluate the success rate of SABG with the addition of BG 45S5 and to highlight the prognostic factors. Patients who underwent operation between 2015 and 2021 and had follow-up cone-beam computed tomography (CBCT) were analyzed. Multivariate analysis was performed to determine factors influencing radiographic success. A total of 102 SABG were analyzed. They were unilateral total cleft lip and palate (49, 48.0%). The mean age at surgery was 9.32 ± 3.09 years. Surgeries were performed mainly outside a syndromic context and without a family history after orthodontic preparation. The radiographic success rate at 1 year was 80.4%. Mixed dentition stage (odds ratio [OR] = 7.3, p = 0.024), absence of syndromic context (OR = 20.7, p = 0.024) and female sex (OR = 4.88, p = 0.021) were factors predictive of surgical success. The use of BG 45S5 instead of autograft is relevant for SABG, with a 1-year success rate of over 80%. The stage of mixed dentition, the absence of syndromic context, and female sex were factors for good prognosis.

Cone Beam Computed Tomographic Analysis Demonstrates a 94% Radiographic Success Rate in 783 Alveolar Bone Grafts

PURPOSE

Success of alveolar bone grafting has been estimated using 2-dimensional periapical radiographs that are associated with image distortion. Cone beam computed tomography (CBCT) accurately displays 3-dimensional anatomy. This study sought to develop and apply a radiographic measure of alveolar bone grafting success using CBCT.

METHODS

This was a retrospective case series composed of patients with cleft lip/palate who had iliac crest bone grafting by 1 surgeon from 2005 to 2020. CBCT scans were obtained ≥4 months after graft. The outcome variables included vertical bone height on cleft adjacent teeth, labiopalatal thickness, and nasal floor symmetry and were scored using a 1 to 4 ordinal scale. Vertical height was determined by the distance from the cementoenamel junction to the marginal bone level of cleft adjacent teeth (1: ≥75% root length, 2: ≥50 to <75%, 3: ≥25 to <50%, 4: <25%), labiopalatal thickness was scored by comparing graft thickness with root width of cleft adjacent teeth (1: <50%, 2: ≥50, 3: ≥75%, 4: ≥100%), and piriform symmetry was established by comparing the nasal floor height between sides (1: ≥6 mm, 2: ≥3 and < 6 mm, 3: ≥1 and < 3 mm, 4: a score of ≥3 < 1 mm). To be considered a successful graft, each dimension scored ≥3. Grafts were also successful if piriform symmetry scored 2, when all other measures indicated success.

RESULTS

The sample was composed of 618 patients with 783 alveolar cleft sites. Subjects' median age was 10.0 (interquartile range 1.6 years), and 59% were male. CBCT scans were obtained a median of 9.7 months (interquartile range 68.8 months) after grafting. There was good-to-excellent intrarater and inter-rater agreement for measurements. Alveolar bone grafting was radiographically successful in 94% of patients.

CONCLUSIONS

This is a valid and reliable assessment tool, and when applied to a large cohort, it demonstrated a 94% graft success rate. Future studies will identify predictor variables associated with bone graft outcomes.

Frequency of Additional Congenital Dental Anomalies in Children with Cleft Lip, Alveolar and Palate

The aim of the study was to assess the risk of incidence of additional congenital dental anomalies in children with nonsyndromic cleft lip, alveolar and/without palate (CL/P). Hypodontia, hyperdontia and canines impaction was recognized. From patients with CL/P treated at the Clinic of Congenital Facial Deformities in Chair and Department of Jaw Orthopedics Medical University of Lublin, 56 subjects were randomly selected. On the panoramic radiographs taken at the age of 8-12 years, the angle of upper unerupted canines was measured using Westerlund's recommendations. The supernumerary teeth and hypodontia were checked. The procedures: maxillary expansion, secondary alveolar bone graft (SABG) and extraction of primary canines were noted. The frequency of canines impaction was 5.36%. Hypodontia was found in 37.5% of patients; hyperdontia was present in 23.21% of patients. No influence of procedures (expansion of the maxilla, SABG, deciduous canines extraction) on permanent maxillary canine eruption was proved. Patients with CL/P are exposed to the unfavorable position of unerupted maxillary canines most frequently in the cleft area of complete cleft. Maxillary lateral incisor on the cleft side is most frequently affected with congenital anomaly. Hypodontia and hyperdontia do not influence maxillary canine impaction. Good clinical result was achieved with an applied approach, which should be widely introduced.

A novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography

PURPOSE

Radiographic scales, based on plain radiographs, for the evaluation of alveolar cleft repair, have certain weaknesses and are thought to overestimate to some degree the success of the surgical intervention. The aim of this study was the presentation of a novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Patients treated with secondary osteoplasty for unilateral or bilateral alveolar cleft were evaluated using the Bergland and Enemark scales, as well as the novel success scale, which measures the bone height, the bone width and the level of the nasal floor.

RESULTS

A total of 44 patients with a total of 53 alveolar cleft sites were included. According to the new scale, 60% of the cases were defined as successful, with moderate (kappa = 0.511) or substantial (kappa = 0.718) agreement, between the new scale and the Bergland or Enemark scale, respectively. Statistically significant correlation was reported between the new success scale and the closure of space of the lateral incisor, the patient's age at surgery, the graft revision and the presence of residual fistula.

CONCLUSIONS

The novel success scale for evaluating alveolar cleft repair using CBCT takes into consideration all dimensions of the bony bridge. Future application is necessary for validation of its potential value.

Paediatric oral & maxillofacial surgery

Children have differences in their physiology, anatomy and they are continuing to grow and develop. The management of pathology, trauma, deformity and upper airway obstruction in the young growing patient has to take into account these factors in the treatment planning for these conditions. It is important for Oral & Maxillofacial Surgeons to understand the potential impact of disease or injury on the developing facial skeleton and dentition. This chapter will provide an overview of the some of the major components of paediatric maxillofacial surgery and their management.

Mucosal Dehiscence After Alveolar Bone Graft in Cleft

Cleft lip and palate patient represent a challenging experience for the surgeon. This kind of patients had to be followed by a multidisciplinary team from the beginning to the end to avoid the deformation sequelae. During the several surgical procedures, the bone graft represents a possible procedure that, through the new procedure, could be avoided. Unfortunately, patient treated following the previous procedure must be submitted to alveolar bone graft to coordinate the arch, to restore the maxillary integrity, to allow the correct dentition.