Volumetric comparison of autogenous bone and tissue-engineered bone replacement materials in alveolar cleft repair: a systematic review and meta-analysis

The Use of Platelet Concentrates in the Reconstruction of the Alveolar Cleft Defect: A Systematic Review and Meta-Analysis

OBJECTIVE

Evaluate quantitative and qualitative outputs when comparing the incidence of platelet concentrates (PCs) combined with autogenous bone grafts to an autograft control group for the reconstruction of alveolar cleft defects.

DESIGN

Systematic review and meta-analysis.

PATIENTS/PARTICIPANTS

Randomized and nonrandomized controlled clinical trials where PCs were used in the reconstruction of alveolar cleft defects.

INTERVENTIONS

Use of PCs in combination with autogenous bone graft in the experimental group and autogenous bone graft alone in the control group.

MAIN OUTCOME MEASURE(S)

Average bone formation and bone density were evaluated, mean differences were calculated and pooled by a meta-analysis technique. Additionally, clinical outcomes such as wound dehiscence, closure of the oronasal fistula, pain, swelling, discharges, infections, and bleeding were considered in the qualitative synthesis.

RESULTS

After an evaluation of forty-nine articles, nineteen were considered for the review. The qualitative assessment of bone density, bone formation, and clinical outcomes showed no differences between groups in most of the included studies. The meta-analysis showed no statistical differences between PCs groups when compared to the control group in bone density at three months (mean difference 45.67 HU, P = .23) and six months (mean difference 48.57 HU, P = .64). Neither were statistical differences in the percentage of regenerated bone volume at six months (mean difference 6.39%, P = .15) and the volume of newly formed bone at 12 months (mean difference 0.37 mm3, P = .99).

CONCLUSIONS

There were no significant differences in terms of bone formation, bone density, and clinical outputs between groups.

Use of autologous platelet derivatives for secondary alveoloplasty in patients with cleft lip and palate: a systematic review and meta-analysis

This study aimed to evaluate the effectiveness of autologous platelet derivatives (APD), specifically platelet-rich plasma (PRP) or platelet-rich fibrin (PRF), combined with autogenous iliac crest bone grafts in secondary alveoloplasty for patients with cleft lip and palate. Electronic databases, relevant journals, and reference lists of included studies were searched until July 2022. Best-evidence synthesis was performed to draw conclusions. After the search strategies, 12 randomized controlled trials were included that provided data on six outcomes: newly formed bone, mean bone loss in height and width, bone density, functionality, and postoperative complications. Two authors independently assessed the risk of bias, and the certainty of evidence was assessed using the GRADE approach. The pooled results suggest that there is uncertainty as to whether the combination of APDs with autogenous iliac crest bone grafts improves the percentage of newly formed bone, as the certainty of the evidence was assessed as very low. It may slightly improve the functionality of patients (with low certainty of the evidence) and probably slightly reduces the incidence of postoperative complications (with moderate certainty of evidence). Further randomized clinical trials with standardized methodologies are required to validate these findings.

Bioactive Scaffolds as a Promising Alternative for Enhancing Critical-Size Bone Defect Regeneration in the Craniomaxillofacial Region

Reconstruction of critical-size bone defects (CSDs) in the craniomaxillofacial (CMF) region remains challenging. Scaffold-based bone-engineered constructs have been proposed as an alternative to the classical treatments made with autografts and allografts. Scaffolds, a key component of engineered constructs, have been traditionally viewed as biologically passive temporary replacements of deficient bone lacking intrinsic cues to promote osteogenesis. Nowadays, scaffolds are functionalized, giving rise to bioactive scaffolds promoting bone regeneration more effectively than conventional counterparts. This review focuses on the three approaches most used to bioactivate scaffolds: (1) conferring microarchitectural designs or surface nanotopography; (2) loading bioactive molecules; and (3) seeding stem cells on scaffolds, providing relevant examples of in vivo (preclinical and clinical) studies where these methods are employed to enhance CSDs healing in the CMF region. From these, adding bioactive molecules (specifically bone morphogenetic proteins or BMPs) to scaffolds has been the most explored to bioactivate scaffolds. Nevertheless, the downsides of grafting BMP-loaded scaffolds in patients have limited its successful translation into clinics. Despite these drawbacks, scaffolds containing safer, cheaper, and more effective bioactive molecules, combined with stem cells and topographical cues, remain a promising alternative for clinical use to treat CSDs in the CMF complex replacing autografts and allografts.

Differences in Practice in Alveolar Bone Grafting Among American Cleft Palate-Craniofacial Association Members

The purpose of this study is to determine areas of agreement and disagreement among American Cleft Palate-Craniofacial Association (ACPA)members in the clinical practice of alveolar bone grafting (ABG), to guide further research to optimize ABG practices.

A cross-sectional survey was conducted.

The respondents were in an academic, combination, or private practice.

The respondents were either plastic or oral and maxillofacial surgeons (OMFS) from various countries.

A de-identified 24-question online survey was distributed to ACPA surgeon members utilizing the Research Electronic Data Capture (REDCap) tool.

Data collected included surgeon specialty, use of various alveolar bone graft surgical techniques, as well as protocols.

There was more variability than consensus between specialties with regards to the preoperative workup, timing of surgery, materials used for bone graft, surgical techniques, perioperative management, and postoperative evaluation. There was consensus on grafting during mixed dentition, not staging soft and hard tissue closure, and using iliac crest for primary and secondary grafting. Disagreements involved factors used to time the procedure and type of imaging used to assess viability. Technical differences involved incision type, part of bone grafted, use of minimally invasive technique, and material used for revisions.

Aside from areas of consensus among surgeons on ABG, several areas, including use of bone substitutes in revision grafting, incision and type of iliac crest graft used during initial grafting, and postoperative protocols, had no consensus. These areas should be targets of further research to determine if there truly is an optimal method to perform ABG.

The study was approved by the University of Illinois at Chicago Institutional Review Board. A de-identified 24-question online survey was distributed to surgeon members of the ACPA utilizing the REDCap tool on August 7, 2020. The survey questions consisted of multiple choice and multiple selection questions including an option to select "other" and specify the information in a blank space. Data collected included surgeon specialty, use of various alveolar bone graft surgical techniques, as well as pre and postoperative protocols. The full survey is included in online Supplemental material. Data analysis was performed in SPSS Statistics 27 (IBM Corp.). Descriptive statistics were performed, and chi-square was used to test for significant differences in survey responses between groups.

Evidence Mapping and Quality Analysis of Systematic Reviews on Various Aspects Related to Cleft Lip and Palate

BACKGROUND

Management of cleft lip and palate is interdisciplinary. An evidence-mapping approach was envisaged to highlight the existing gaps in this field, using only the highest level of evidence.

OBJECTIVES

To conduct evidence mapping and quality analysis of systematic reviews and meta-analyses related to any aspect of cleft lip and palate.

SEARCH METHODS

The cleft lip and palate field was divided into 9 domains and 50 subdomains and a method of categorization of systematic reviews was established. A comprehensive search strategy was carried out in seven databases along with the search of gray literature and references of included articles.

SELECTION CRITERIA

Systematic reviews related to any aspect of cleft lip and palate, conducted by a minimum of two reviewers, with a comprehensive search strategy and adequate quality analysis were included.

DATA COLLECTION AND ANALYSIS

A self-designed, pre-piloted data-extraction sheet was used to collect information that was analyzed through an expert group discussion. Quality analysis was performed using ROBIS-I, AMSTAR 2, and the PRISMA checklist.

RESULTS

A total of 144 systematic reviews published between 2008 and 2022 were included. The largest number of these could be categorized in the therapeutic domain (n = 58). A total of 27% of the studies were categorized as inconclusive, 40% as partially conclusive, and 33% as conclusive. As per ROBIS-I, 77% of reviews had high risk of bias while 58% were graded as critically low in quality as per AMSTAR 2. The majority of systematic reviews showed low reporting errors.

CONCLUSIONS

The majority of systematic reviews related to cleft lip and palate relate to therapeutic and prognostic domains and show high risk of bias and critically low quality regardless of the source journal. The results of this paper might serve as a starting point encouraging authors to carry out high-quality research where evidence is lacking.

REGISTRATION

A multidisciplinary expert-group formulated an a priori protocol, registered in Open Science Framework (DOI 10.17605/OSF.IO/NQDV2).

Maxillary Arch Dimensions in Children with Unilateral Cleft Lip and Palate Receiving Alveolar Bone Grafting

OBJECTIVE

To analyse the maxillary arch dimensions of children aged 9 and 12 with unilateral cleft lip and palate (UCLP) who received orthodontic treatment and secondary alveolar bone grafting.

DESIGN

This retrospective cohort study was performed on 30 patients with UCLP.

SETTING

All patients were treated at the Cleft Lip and Palate Centre, which is part of the University Medical Centre Amsterdam and Academic Centre for Dentistry Amsterdam, the Netherlands.

PATIENTS/PARTICIPANTS

Children with non-syndromic UCLP who received pre- and postsurgical orthodontics combined with secondary alveolar bone grafting between the ages of 9 and 12 years were included.

MAIN OUTCOME MEASURES

Maxillary arch dimensions were assessed on 60 digitised dental casts with measurements of the intermolar widths, interpremolar widths, arch perimeters, arch lengths, arch widths, and palatal depths.

RESULTS

The results of a paired-samples t-test revealed a statistically significant increase (P < .05) in intermolar width 1, intermolar width 3, interpremolar width 1, arch perimeter, and arch width between the ages of 9 (T0) and 12 (T1). Intermolar width 2 and the palatal depth decreased statistically significantly between T0 and T1.

CONCLUSIONS

Analysis of maxillary arch dimensions of children with UCLP indicates significant changes between 9 and 12 years of age. This suggests that orthodontic treatment and secondary alveolar bone grafting can be effective in improving maxillary arch dimensions. However, there is a need for collaborative research and data collection in order to provide sensible and evidence-based care to patients with cleft lip and palate.

Oral cavity-derived stem cells and preclinical models of jaw-bone defects for bone tissue engineering

BACKGROUND

Jaw-bone defects caused by various diseases lead to aesthetic and functional complications, which can seriously affect the life quality of patients. Current treatments cannot fully meet the needs of reconstruction of jaw-bone defects. Thus, the research and application of bone tissue engineering are a "hot topic." As seed cells for engineering of jaw-bone tissue, oral cavity-derived stem cells have been explored and used widely. Models of jaw-bone defect are excellent tools for the study of bone defect repair in vivo. Different types of bone defect repair require different stem cells and bone defect models. This review aimed to better understand the research status of oral and maxillofacial bone regeneration.

MAIN TEXT

Data were gathered from PubMed searches and references from relevant studies using the search phrases "bone" AND ("PDLSC" OR "DPSC" OR "SCAP" OR "GMSC" OR "SHED" OR "DFSC" OR "ABMSC" OR "TGPC"); ("jaw" OR "alveolar") AND "bone defect." We screened studies that focus on "bone formation of oral cavity-derived stem cells" and "jaw bone defect models," and reviewed the advantages and disadvantages of oral cavity-derived stem cells and preclinical model of jaw-bone defect models.

CONCLUSION

The type of cell and animal model should be selected according to the specific research purpose and disease type. This review can provide a foundation for the selection of oral cavity-derived stem cells and defect models in tissue engineering of the jaw bone.

Three-Dimensional Impression of Biomaterials for Alveolar Graft: Scoping Review

Craniofacial bone defects are one of the biggest clinical challenges in regenerative medicine, with secondary autologous bone grafting being the gold-standard technique. The development of new three-dimensional matrices intends to overcome the disadvantages of the gold-standard method. The aim of this paper is to put forth an in-depth review regarding the clinical efficiency of available 3D printed biomaterials for the correction of alveolar bone defects. A survey was carried out using the following databases: PubMed via Medline, Cochrane Library, Scopus, Web of Science, EMBASE, and gray literature. The inclusion criteria applied were the following: in vitro, in vivo, ex vivo, and clinical studies; and studies that assessed bone regeneration resorting to 3D printed biomaterials. The risk of bias of the in vitro and in vivo studies was performed using the guidelines for the reporting of pre-clinical studies on dental materials by Faggion Jr and the SYRCLE risk of bias tool, respectively. In total, 92 publications were included in the final sample. The most reported three-dimensional biomaterials were the PCL matrix, β-TCP matrix, and hydroxyapatite matrix. These biomaterials can be combined with different polymers and bioactive molecules such as rBMP-2. Most of the included studies had a high risk of bias. Despite the advances in the research on new three-dimensionally printed biomaterials in bone regeneration, the existing results are not sufficient to justify the application of these biomaterials in routine clinical practice.

Correlations between radiological and histological findings of bone remodelling and root resorption in a rodent cleft model

Background

The evaluation of bone remodelling and dental root resorption can be performed by histological techniques or micro-computed tomography (micro-CT). The present study aimed to evaluate the relationship between these two procedures in the context of cleft repair in a rat model.

Methods

The reconstructed maxillae and the orthodontically-moved first molar of 12 rats were analysed for correlations between the histological and radiological findings retrospectively. The alveolar cleft repairs were performed using bone autografts or (human) xenografts. Four weeks after the operation, the intervention of the first molar protraction was initiated and lasted for eight weeks. The newly formed bone and the root resorption lacunae were determined via histology. In the micro-CT analysis, the average change of bone mineral density (BMD), bone volume fraction (BV/TV), trabecular thickness and trabecular separation of the jaw, as well as the volume of the root resorptions were determined. The Pearson correlation coefficient was applied to study the associations between groups.

Results

Positive correlations were found only between the newly formed bone (histology) and BMD changes (micro-CT) in the autograft group (r = 0.812, 95% CI: 0.001 to 0.979, p = 0.05). The relationship of newly formed bone and BV/TV was similar but not statistically significant (r = 0.691, 95% CI: −0.274 to 0.963, p = 0.013). Regarding root resorption, no significant correlations were found.

Conclusions

Due to the lack of correlation between histological and radiological findings of bone remodelling and the development of root resorptions, both methods should be combined in this cleft model in rats for a comprehensive analysis.

The strategy of composite grafting with BMP2-Loaded calcium phosphate cements and autogenous bone for alveolar cleft reconstruction

Purpose: To remedy the drawbacks of traditional autogenous bone harvesting in alveolar bone grafting (ABG), a novel strategy of composite grafting with BMP2-loaded calcium phosphate cements (BMP2-CPC) and autogenous bone harvested by minimally invasive technique was developed and evaluated for its bone-repairing efficacy.

Materials and methods: A chart review was conducted for 19 patients with unilateral alveolar clefts who underwent secondary ABG from 2017 to 2020. Of the enrolled patients, 9 patients underwent grafting with autogenous bone harvested by traditional trap door technique (group I), and 10 patients underwent grafting with the composite graft comprising BMP2-CPC and autogenous bone harvested by minimally invasive technique at a ratio of 1:1 by volume (group II). The clinical performance of the composite graft was comprehensively evaluated in terms of clinical, radiographic and histological perspectives.

Results: The present results demonstrated that the composite graft exhibited satisfactory bone-repairing efficacy comparable to that of the autogenous bone graft on the premise of lower amount of harvested bone. The post-surgical resorption of bone volume and vertical height of grafted area was significantly slower in group II. The favourable resorption performance of BMP2-CPC contributed to preserving the post-surgical bony contour reconstructed with the composite graft.

Conclusion: The composite graft comprising BMP2-CPC and autogenous bone harvested by minimally invasive technique was demonstrated to be an eligible alternative for application in ABG, especially for its improved resorption performance in preserving post-surgical bony contour.

Development of root resorption during orthodontic tooth movement after cleft repair using different grafting materials in rats

OBJECTIVE

The aim of the present study was to investigate the influence of three grafting materials for cleft repair on orthodontic tooth movement in rats.

MATERIALS AND METHODS

Artificial alveolar clefts were created in 21 Wistar rats and were repaired 4 weeks later using autografts, human xenografts and synthetic bone substitute (beta-tricalcium phosphate/hydroxyapatite [β-TCP/HA]). A further 4 weeks later, the first molar was moved into the reconstructed maxilla. Microfocus computed tomography (μCT) was performed six times (T0-T5) to assess the tooth movement and root resorption. After 8 weeks, the affected reconstructed jaw was resected for histopathological investigation.

RESULTS

Total distances reached ranged from 0.82 ± 0.72 mm (β-TCP/HA) to 0.67 ± 0.27 mm (autograft). The resorption was particularly determined at the mesiobuccal root. Descriptive tooth movement slowed and root resorption increased slightly. However, neither the radiological changes during tooth movement (µCT T1 vs. µCT T5: autograft 1.85 ± 0.39 mm³ vs. 2.38 ± 0.35 mm³, p = 0.30; human xenograft 1.75 ± 0.45 mm³ vs. 2.17 ± 0.26 mm³, p = 0.54; β-TCP/HA: 1.52 ± 0.42 mm³ vs. 1.88 ± 0.41 mm³, p = 0.60) nor the histological differences after tooth movement (human xenograft: 0.078 ± 0.05 mm²; β-TCP/HA: 0.067 ± 0.049 mm²; autograft: 0.048 ± 0.015 mm²) were statistically significant.

CONCLUSION

The autografts, human xenografts or synthetic bone substitute used for cleft repair seem to have a similar effect on the subsequent orthodontic tooth movement and the associated root resorptions.

CLINICAL RELEVANCE

Development of root resorptions seems to have a secondary role in choosing a suitable grafting material for cleft repair.

A Holistic Approach for the Identification of Success Factors in Secondary Cleft Osteoplasty

Cleft lip and palate belong to the most frequent craniofacial anomalies. Secondary osteoplasty is usually performed between 7 and 11 years with the closure of the osseus defect by autologous bone. Due to widespread occurrence of the defect in conjunction with its social significance due to possible esthetic impairments, the outcome of treatment is of substantial interest. The success of the treatment is determined by the precise rebuilding of the dental arch using autologous bone from the iliac crest. A detailed analysis of retrospective data disclosed a lack of essential and structured information to identify success factors for fast regeneration and specify the treatment. Moreover, according to the current status, no comparable process monitoring is possible during osteoplasty due to the lack of sensory systems. Therefore, a holistic approach was developed to determine the parameters for a successful treatment via the incorporation of patient data, the treatment sequences and sensor data gained by an attachable sensor module into a developed Dental Tech Space (DTS). This approach enables heterogeneous data sets to be linked inside of DTS, archiving and analysis, and is also for future considerations of respective patient-specific treatment plans.

Efficacy of regenerative medicine for alveolar cleft reconstruction: A systematic review and meta-analysis

Objective:

Objective: To analyze the efficacy and complications of regenerative medicine compared to autogenous bone graft for alveolar cleft reconstruction.

Method:

Method: Electronic search was done in PubMed, Scopus, Embase and Cochrane database for studies published until May 2021. No limitations were considered for the type of the included studies. The risk of bias (ROB) of the studies was assessed using the Cochrane Collaborations and NIH quality assessment tool. Meta-analyses were performed to assess the difference in the amount of bone formation and rate of complications. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for analyzing the level of the evidence.

Results:

Results: Among a total of 42 included studies, 21 studies used growth factors, 16 studies delivered cells, and five studies used biomaterials for bone regeneration of the alveolar cleft. Results showed no significant difference in the amount of bone formation between bone morphogenic protein-2 and iliac graft treated patients after six months (P=0.44) and 12 months (P=0.17) follow-up. Besides, higher swelling (OR=9.46,P<0.01) and less infection (OR=0.19,P=0.01) observed in BMP treated patients. Using stem cells can reduce the post-treatment pain (OR=0.04,P=0.01) but it has no significant impact on other complications (P>0.05). Using tissue engineering methods reduced the operation time (SD=1.06,P<0.01). GRADE assessment showed that results regarding the amount of bone formation volume after six and 12 months have low level of evidence.

Conclusion:

Conclusion: Tissue engineering methods can provide a comparable amount of bone formation as of the autogenous graft and reduce some of the complications, operation time and hospitalization duration.

Effectiveness of rhBMP-2 versus iliac autogenous bone graft in reconstructive surgery of cleft patients: an umbrella review

The objective of this umbrella review was to determine the effectiveness of rhBMP-2 in the reconstructive surgery of cleft patients through an evaluation of bone filling and volume of newly formed bone in the cleft area. A systematic search was carried out in PubMed/ Medline, Scopus, Cochrane Database of Abstracts of Reviews of Effects (DARE), Latin American and Caribbean Health Sciences Literature (LILACS), and the System for Information on Grey Literature in Europe (SIGLE) via Open Grey, until June 2020. Risk of bias was assessed using the ROBIS tool. A total of 2739 articles were identified and, based on the inclusion and exclusion criteria, six were included for final evaluation. The bone filling rate was 74.23% in the rhBMP-2 group and 72.38% in the autogenous group. Regarding the risk of bias, none of the articles had a low risk, four had an uncertain risk, and two a high risk. The results of this umbrella review show that the studies had high and uncertain risks of bias, and high heterogeneity. There was a lack of evidence regarding the possible complications offered by this therapy. The recommendation to use BMP-2 for alveolar cleft reconstruction, especially in a paediatric population, should be viewed with caution. New primary studies are needed to assess this variable and safely determine the use of rhBMP-2 in reconstructive surgery for cleft patients.

A systematic review on regenerative alveolar graft materials in clinical trials: Risk of bias and meta-analysis

BACKGROUND

Alveolar cleft grafting is a necessary procedure to restore bone defects. Randomized clinical trials (RCTs) are regarded as a golden standard for investigating the efficacy of treatments. Nevertheless, risk of bias (RoB) can still affect the validity of these trials. We aimed to conduct a systemic review of all control trials (CTs) using regenerative materials for alveolar cleft reconstructions to evaluate their RoB and perform a meta-analysis of new bone formation.

METHODS

Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE AND Google Scholar were searched up to October 2020. Thereafter, the articles underwent quality assessment (according to the Jadad scale and the Delphi list) for the evaluation of the RoB.

RESULTS

A total of 15 trials met the inclusion criteria, none of which reached a full score. Of these, 20% didn't randomize the trails, 73,33% failed to describe the way of randomization, and none reported the double-blinded criteria. Furthermore, allocation concealment (99.9%), intention to treat (100%), and patient awareness (100%) were inadequately described. The meta-analysis found no significant difference between regenerative materials and iliac crest graft.

CONCLUSION

This review showed high RoB in CTs implying quality improvement of CTs is necessary. Meta-analysis showed no significant difference between the regenerative materials and autogenous grafts.

Evaluation of different grafting materials for alveolar cleft repair in the context of orthodontic tooth movement in rats

To minimize the postoperative risks posed by grafting autologous transplants for cleft repair, efforts are being made to improve grafting materials for use as potential alternatives. The aim of this study was to compare the bone graft quality of different bone substitutes including the gold standard autografts during the healing processes after cleft repair in the context of orthodontic treatment. In 21 Wistar rats, a complete, continuity-interrupting cleft was created. After 4 weeks, cleft repair was performed using autografts from the hips’ ischial tuberosity, human xenografts, or synthetic bone substitutes [beta-tricalcium phosphate (β-TCP)/hydroxyapatite (HA)]. After another 4 weeks, the first molar movement was initiated in the reconstructed jaw for 8 weeks. The bone remodeling was analyzed in vivo using micro-computed tomography (bone mineral density and bone volume fraction) and histology (new bone formation). All the grafting materials were statistically different in bone morphology, which changed during the treatment period. The β-TCP/HA substitute demonstrated less resorption compared to the autologous and xenogeneic/human bone, and the autografts led to a stronger reaction in the surrounding bone. Histologically, the highest level of new bone formation was found in the human xenografts, and the lowest was found in the β-TCP/HA substitute. The differences between the two bone groups and the synthetic materials were statistically significant. Autografts were confirmed to be the gold standard in cleft repair with regard to graft integration. However, parts of the human xenograft seemed comparable to the autografts. Thus, this substitute could perhaps be used as an alternative after additional tissue-engineered modification.

Comparison of Two Methods for Presurgical Volumetric Evaluation of Alveolar Cleft Bone Defects Using Computer-Aided Engineering

ABSTRACT

Precise volumetric evaluation of the alveolar cleft facilitates accurate preparation of bone substitutes and reduces donor site morbidity. This study investigates 2 advanced presurgical volumetric assessment methods that use computer-aided engineering (CAE) software. Preoperative computed tomography (CT) scans from 20 unilateral alveolar cleft patients undergoing secondary alveolar bone grafting (SABG) were analyzed by CAE software. Cleft defect volumes were calculated using the mirror-reversed technique and the subtraction method. The mirror-reversed technique determines defect volume by reversing the noncleft side to the cleft side. The subtraction method determines defect volume by subtracting a mask of the preoperative cleft from a mask generated after simulated cleft filling. The mean defect volumes and calculation times of the mirror-reversed technique (1.27 ± 0.35 cm3; 11.80 ± 1.79 seconds) and the subtractive method (1.23 ± 0.32 cm3; 9.43 ± 1.35 seconds) did not differ significantly. In Bland-Altman analysis the 2 methods were equivalent for alveolar cleft defect assessment. Both methods exhibited acceptable interobserver reliability, high precision, clinical convenience, time efficiency, and high reproducibility, and can serve as valuable tools for the planning and execution of SABG. The subtraction method has broader potential applicability and can simulate intraoperative bone grafting more effectively.

Regenerative Strategies in Cleft Palate: An Umbrella Review

(1) Background: Alveolar bone defects or decreased alveolar bone height and width may have different causes, such as cleft palate. Regenerative procedures in oro-dental defects are challenging due to anatomical factors and the distinct cell populations involved. The iliac crest bone graft remains the gold-standard for cleft palate closure. However, tissue regeneration approaches have been employed and their outcome reviewed, but no conclusions have been made about which one is the gold-standard. (2) Methods: this umbrella review aims to critically appraise the effectiveness of the current approaches in bone defects regeneration in non-syndromic patients with cleft palate. A search was performed in PubMed, Cochrane Library, Scopus, Web of Science and EMBASE databases. (3) Results: Systematic reviews of randomized and non-randomized controlled trials with or without meta-analysis were included. Nine articles were included in the qualitative analysis and five in the quantitative one. The included studies quality was evaluated with AMSTAR2. (4) Conclusions: The use of new regenerative strategies, such as bone morphogenic protein 2, appears to provide similar results regarding bone volume, filling, and height to the standard technique with the iliac crest bone graft.

Establishing a new alveolar cleft model in rats to investigate the influence of jaw reconstructions on orthodontic tooth movement

BACKGROUND

The aim of the present investigation was to develop a new cleft model in rats that allows alveolar cleft repair and subsequent tooth movement.

METHODS

A complete continuity-interrupting alveolar cleft was performed on the left-side maxillae of 33 rats through ultrasonic surgery. The clefts were filled with bone wax, and microCT scans were done to analyze the cleft size. After four weeks, the cleft repair was completed using autologous, xenogeneic (human), or synthetic bone substitute. After an additional four weeks, the orthodontic tooth movement was initiated.

RESULTS

Fourteen rats died during the research, and the study design was constantly adapted accordingly. The main reasons for death included breathing problems during or immediately after the experimental activities (eight animals), followed by two deaths due to circulatory failures. In the remaining 19 animals, the average cleft size was about 2.70 ± 0.46 × 2.01 ± 0.25 × 1.18 ± 0.20 mm, and the mean velocity of orthodontic tooth movement after seven days was between 0.21 ± 0.08 mm in the autologous group and 0.50 ± 0.54 mm in the xenogeneic group. After 56 days, the mean values ranged between 0.67 ± 0.27 mm in the autologous group and 0.82 ± 0.72 mm in the synthetic group.

CONCLUSIONS

Surgical interventions in the oral cavity of rats requires a stronger anesthesia and lead to increased risk of coolant and coagulated blood aspiration. The new alveolar cleft model in rats allows for subsequent orthodontic tooth movement after cleft repair, but only in the mesial root of the first molar.

Alveolar cleft bone grafting: factors affecting case prognosis

Objectives

The goal of this retrospective study was to determine the significance and impact of several factors on the alveolar cleft bone grafting procedure.

Materials and Methods

The medical records were reviewed. In addition, x-rays were checked. The size of every cleft was measured in this retrospective study. The analyzed factors included sex, age, type of cleft, size of the cleft, and the type of flap used in surgery. The patients were characterized into group A (no complications, Bergland scale 1 or 2), group B (complications or Bergland scale 3), or group C (failure cases). Statistical analysis was performed with a P-value set at 0.05.

Results

There were 32 cases in group A, 26 in group B, and 9 in group C. Multinomial logistic regression showed an association between the type of the cleft and the size of the cleft, with the presence of complications, or achieving type 3 on the Bergland scale, with odds ratios of 5.118 and 6.000, respectively. The type of cleft was related to failure with an odds ratio of 4.833. Given a small sample, statistical analysis could not be performed to evaluate the relationship between the size of the cleft and group C. Age, sex, and the type of the flap were not significant factors.

Conclusion

The cleft size of more than 10 mm and bilateral clefts were listed regarding their effect on the procedure. Clinicians should not overlook these factors. In addition, patients must be informed of any risks that are present.

Ischial tuberosity: new donor site for bone grafts in animal cleft research

In the context of cleft repair in animal research in rat models, different areas can be used for bone grafting. The aim of the present study was to present the tuberosity of the ischium as a new donor site and to evaluate its quality in relation to an artificial alveolar cleft. Four weeks after creating experimental alveolar clefts in seven Wistar rats, the repair was performed in the now twelve-week-old male animals using bone blocks grafted from the ischial tuberosity. Two days before surgery and two as well as twenty-eight days after surgery, microCT scans were performed, and the grafted bone blocks were analyzed regarding height, width, thickness, and volume. Additionally, bone mineral density (BMD) and bone volume fraction (BV/TV) were measured in the repaired cleft. The mean bone volume of the graft was about 19.77 ± 7.77mm³. Immediately after jaw reconstruction the BMD and BV/TV were about 0.54 ± 0.05 g/cm³ and 54.9 ± 5.07% for the transplant and about 1.13 ± 0.08 g/cm³ and 94.5 ± 3.70%, respectively, for the surrounding bone. Four weeks later the BMD and BV/TV were about 0.57 ± 0.13 g/cm³ and 56.60 ± 13.70% for the transplant and about 11.17 ± 0.07 g/cm³ and 97.50 ± 2.15%, respectively, for the surrounding bone. A hip fracture was found in four of the animals after surgery. The ischial tuberosity offers large bone blocks, which are sufficient for cleft repair in the rat model. However, the bone quality regarding BMD and BV/TV is less compared with the surrounding bone of the alveolar cleft, even after a period of 4 weeks, despite recognizable renovation processes.

Functional Validation of a New Alginate-based Hydrogel Scaffold Combined with Mesenchymal Stem Cells in a Rat Hard Palate Cleft Model

Background:

One of the major difficulties in cleft palate repair is the requirement for several surgical procedures and autologous bone grafting to form a bony bridge across the cleft defect. Engineered tissue, composed of a biomaterial scaffold and multipotent stem cells, may be a useful alternative for minimizing the non-negligible risk of donor site morbidity. The present study was designed to confirm the healing and osteogenic properties of a novel alginate-based hydrogel in palate repair.

Methods:

Matrix constructs, seeded with allogeneic bone marrow–derived mesenchymal stem cells (BM-MSCs) or not, were incorporated into a surgically created, critical-sized cleft palate defect in the rat. Control with no scaffold was also tested. Bone formation was assessed using microcomputed tomography at weeks 2, 4, 8, and 12 and a histologic analysis at week 12.

Results:

At 12 weeks, the proportion of bone filling associated with the use of hydrogel scaffold alone did not differ significantly from the values observed in the scaffold-free experiment (61.01% ± 5.288% versus 36.91% ± 5.132%; p = 0.1620). The addition of BM-MSCs stimulated bone formation not only at the margin of the defect but also in the center of the implant.

Conclusions:

In a relevant in vivo model of cleft palate in the rat, we confirmed the alginate-based hydrogel’s biocompatibility and real advantages for tissue healing. Addition of BM-MSCs stimulated bone formation in the center of the implant, demonstrating the new biomaterial’s potential for use as a bone substitute grafting material for cleft palate repair.

An Accurate Volumetric Analysis Method for Evaluating Outcomes of Alveolar Cleft Reconstruction

An accurate volumetric analysis method for evaluating the outcomes of different types of alveolar cleft reconstruction is essential because it can help determine which graft material is more effective, confirm favorable times for alveolar bone grafting, and improve surgical techniques. This study aimed to introduce a novel method of precisely calculating the bone formation ratio using computer-aided engineering after surgery. A patient with a unilateral alveolar cleft who was treated with anterior iliac crest bone grafting was enrolled in this study. Helical computed tomography scans were performed preoperatively and 12 months postoperatively. The Digital Imaging and Communications in Medicine (DICOM) data were reconstructed as three-dimensional images and saved in the STL format by using Mimics software. STL data were processed by Geomagic Wrap 2017, using the Boolean operation, the newly formed bone of the alveolar was segmented by identifying the differences between the preoperative and the postoperative three-dimensional images. For this patient, the mean volume of the newly formed bone was 0.387 cm, the morphology was clear, the bone formation ratio was 41.4%, the mean time required for calculating the newly formed bone volume was 23 minutes, and the bone survival ratio was 38.7%. This method is a clinically practical, accurately measurement and time-saving method to evaluate the outcome of alveolar cleft reconstruction. Both the volumetric assessment and morphological analysis of the newly formed bone could be determined in a precise manner.

A novel accurate volumetric analysis protocol for evaluating secondary alveolar cleft reconstruction

An accurate volumetric analysis protocol for secondary alveolar cleft reconstruction is essential. It can help confirm favorable times for bone grafting, determine which graft material is more effective, and improve surgical techniques. This study aimed to introduce a novel protocol for precisely calculating the bone formation ratio (BF%) using computer-aided engineering. The helical computed tomography (CT) datasets of 14 patients who underwent alveolar cleft reconstruction was included in this study. CT scans performed preoperatively and 1 year postoperatively were evaluated by two investigators. Digital Imaging and Communications in Medicine (DICOM) data were reconstructed as three-dimensional (3D) images using Mimics software and processed by Geomagic Wrap (2017). Using the Boolean operation, the newly formed bone of the alveolar cleft was segmented by identifying the differences between pre- and postoperative 3D images. The volumetric assessment and morphological analysis of the newly formed bone could be determined in a precise manner, the mean BF% was 47.7% ± 16.4%, the mean time required for calculating was 23.57 ± 3.64 min. For the difference in the volume of newly formed bone between the two observers, the intraclass correlation coefficient (ICC) was 0.92, p < 0.001. This method is clinically practical and precise measurement, which has good reproducibility for evaluating outcome of different grafting materials for alveolar clefts.

Extracellular Matrix Composition and Remodeling: Current Perspectives on Secondary Palate Formation, Cleft Lip/Palate, and Palatal Reconstruction

Craniofacial development comprises a complex process in humans in which failures or disturbances frequently lead to congenital anomalies. Cleft lip with/without palate (CL/P) is a common congenital anomaly that occurs due to variations in craniofacial development genes, and may occur as part of a syndrome, or more commonly in isolated forms (non-syndromic). The etiology of CL/P is multifactorial with genes, environmental factors, and their potential interactions contributing to the condition. Rehabilitation of CL/P patients requires a multidisciplinary team to perform the multiple surgical, dental, and psychological interventions required throughout the patient's life. Despite progress, lip/palatal reconstruction is still a major treatment challenge. Genetic mutations and polymorphisms in several genes, including extracellular matrix (ECM) genes, soluble factors, and enzymes responsible for ECM remodeling (e.g., metalloproteinases), have been suggested to play a role in the etiology of CL/P; hence, these may be considered likely targets for the development of new preventive and/or therapeutic strategies. In this context, investigations are being conducted on new therapeutic approaches based on tissue bioengineering, associating stem cells with biomaterials, signaling molecules, and innovative technologies. In this review, we discuss the role of genes involved in ECM composition and remodeling during secondary palate formation and pathogenesis and genetic etiology of CL/P. We also discuss potential therapeutic approaches using bioactive molecules and principles of tissue bioengineering for state-of-the-art CL/P repair and palatal reconstruction.