Cleft Palate Repair, Gingivoperiosteoplasty, and Alveolar Bone Grafting

Oral Staphylococcus Species and MRSA Strains in Patients with Orofacial Clefts Undergoing Surgical Rehabilitation Diagnosed by MALDI-TOF MS

This study investigated the occurrence and dynamics of oral Staphylococcus species in patients with orofacial clefts undergoing surgical rehabilitation treatment. Patients (n = 59) were statistically stratified and analyzed (age, gender, types of orofacial clefts, surgical history, and types of previous surgical rehabilitation). Salivary samples were obtained between hospitalization and the return to the specialized medical center. Microbiological diagnosis was performed by classical methods, and MALDI-TOF MS. MRSA strains (SCCmec type II, III, and IV) were characterized by the Decision Tree method. A total of 33 (55.9%) patients showed oral staphylococcal colonization in one, two, or three sampling steps. A high prevalence has been reported for S. aureus (including HA-, MRSA and CA-MRSA), followed by S. saprophyticus, S. epidermidis, S. sciuri, S. haemolyticus, S. lentus, S. arlettae, and S. warneri. The dynamics of oral colonization throughout surgical treatment and medical follow-up may be influenced by (i) imbalances in staphylococcal maintenance, (ii) efficiency of surgical asepsis or break of the aseptic chain, (iii) staphylococcal neocolonization in newly rehabilitated anatomical oral sites, and (iv) total or partial maintenance of staphylococcal species. The highly frequent clinical periodicity in specialized medical and dental centers may contribute to the acquisition of MRSA in these patients.

Comprehensive three-dimensional cone beam computed tomography assessment unilateral alveolar cleft reconstruction using autologous iliac cancellous bone combined with deproteinized bovine bone: A clinical retrospective evaluation

Large-volume autologous iliac cancellous bone grafting for alveolar cleft may lead to undesirable bone resorption and susceptible donor-site morbidity, whereas the addition of deproteinized bovine bone (DBB) could optimize outcomes. This study aimed to evaluate the effectiveness of combining autologous iliac bone with DBB using three-dimensional cone beam computed tomography (3D-CBCT) for better analysis of bone generation than conventional evaluation methods. Thirty-six patients with unilateral alveolar cleft were assigned into two groups. Group A (n = 21) underwent autogenous cancellous bone graft harvested from the anterior iliac crests, while Group B (n = 15) received a composite of autogenous iliac cancellous bone and DBB. Patients in Group B displayed higher bone filling rates (P < 0.0001) and lower bone absorption rates (P < 0.001) than those in Group A at both 6 months and 1 year postoperatively. Additionally, there were directional differences in bone absorption within the bone grafts, with more absorption observed on the alveolar crest and palatal sides than that on the nasal and labial sides (P < 0.001). This study demonstrates that employing a combination of DBB and autologous bone in alveolar cleft repair achieves better outcomes of bone grafting.

Stem Cell-Based Tissue Engineering for Cleft Defects: Systematic Review and Meta-Analysis

This study aimed to analyze the efficacy of stem cell-based tissue engineering for the treatment of alveolar cleft (AC) and cleft palate (CP) defects in animal models.

Systematic review and meta-analysis.

Preclinical studies on alveolar cleft repair in maxillofacial practice.

Electronic search was performed using PubMed, Embase, and Cochrane databases. Pre-clinical studies, where stem cell-based tissue engineering was used in the reconstruction of AC and CP in animal models were included. Quality of the selected articles was evaluated using SYRCLE (SYstematic Review Centre for Laboratory animal Experimentation).

Review of alveolar cleft bone augmentation interventions in preclinical models.

Outcome parameters registered were new bone formation (NBF) and/or bone mineral density (BMD).

Thirteen large and twelve small animal studies on AC (21) and CP (4) reconstructions were included. Studies had an unclear-to-high risk of bias. Bone marrow mesenchymal stem cells were the most widely used cell source. Meta-analyses for AC indicated non-significant benefits in favor of: (1) scaffold + cells over scaffold-only (NBF P = .13); and (2) scaffold + cells over empty control (NBF P = .66; BMD P = .31). Interestingly, dog studies using regenerative grafts showed similar to superior bone formation compared to autografts. Meta analysis for the CP group was not possible.

AC and CP reconstructions are enhanced by addition of osteogenic cells to biomaterials. Directions and estimates of treatment effect are useful to predict therapeutic efficacy and guide future clinical trials of bone tissue engineering.

Osteogenic potency of dental stem cell-composite scaffolds in an animal cleft palate model

Objective

To evaluate the osteogenic potency of stem cells isolated from human exfoliated deciduous teeth (SHED) in polycaprolactone with gelatin surface modification (PCL-GE) and poly (lactic-co-glycolic acid)-bioactive glass composite (PLGA-bioactive glass (BG)) scaffolds after implantation in a rat cleft model.

Methods

Cleft palate-like lesions were induced in Sprague-Dawley rats by extracting the right maxillary first molars and drilling the intact alveolar bone. Rats were then divided into five groups: Control, PCL-GE, PCL-GE-SHED, PLGA-BG, and PLGA-BG-SHED, and received corresponding composite scaffolds with/without SHED at the extraction site. Tissue samples were collected at 2, 3, and 6 months post-implantation (4 rats per group). Gross and histological analyses were conducted to assess osteoid or bone formation. Immunohistochemistry for osteocalcin and human mitochondria was performed to evaluate bone components and human stem cell viability in the tissue.

Results

Bone tissue formation was observed in the PCL-GE and PLGA-BG groups compared to the control, where no bone formation occurred. PLGA-BG scaffolds demonstrated greater bone regeneration potential than PCL-GE over 2-6 months. Additionally, scaffolds with SHED accelerated bone formation compared to scaffolds alone. Osteocalcin expression was detected in all rats, and positive immunoreactivity for human mitochondria was observed in the regenerated bone tissue with PCL-GE-SHED and PLGA-BG-SHED.

Conclusion

PCL-GE and PLGA-BG composite scaffolds effectively repaired and regenerated bone tissue in rat cleft palate defects. Moreover, scaffolds supplemented with SHED exhibited enhanced osteogenic potency.

Clinical significance

PCL-GE and PLGA-BG scaffolds, augmented with SHED, emerge as promising biomaterial candidates for addressing cleft repair and advancing bone tissue engineering endeavors.

Gingivoperiosteoplasty in Children with Cleft Lip and Palate: The Need for Alveolar Bone Grafting

OBJECTIVE

This study aimed to determine the efficacy of gingivoperiosteoplasty (GPP) in preventing alveolar bone grafting (ABG) among children with cleft lip and palate (CLP).

DESIGN/SETTING

Retrospective university hospital single center study.

PATIENTS

Children with CLP treated with GPP from 2000-2015 were included. Those under eight years of age, without definitive conclusions regarding need for ABG or with incomplete data were excluded.

INTERVENTIONS

Included patients were analyzed for demographics, cleft type, age at GPP, associated cleft surgery, use of nasoalveolar molding (NAM), indication for ABG, operating surgeon and presence of residual alveolar fistula. T-tests and Fisher's exact tests were utilized for statistical analysis.

MAIN OUTCOME MEASURE

The need for ABG.

RESULTS

Of the 1682 children identified with CLP, 64 underwent GPP and met inclusion criteria. 78% of patients with CLP who underwent GPP were recommended for ABG. Those who received GPP at a younger age (P = .004) and at the time of initial cleft lip repair (P = .022) were less likely to be recommended for ABG. Patients with complete CLP were more likely to be recommended for ABG than patients with cleft lip and alveolus only (P = .015). The operating surgeon impacted the likelihood of ABG (P = .004). Patient gender, race, ethnicity, laterality, and NAM were not significantly associated with recommendation for ABG.

CONCLUSION

GPP does not preclude the need for ABG. Therefore, the success of ABG after GPP and maxillary growth restriction should be analyzed further to determine if GPP is a worthwhile adjunct to ABG in cleft care.

Microfragmented Fat and Biphasic Calcium Phosphates for Alveolar Cleft Repair: Protocol for a Prospective, Nonblinded, First-in-Human Clinical Study

BACKGROUND

Biphasic calcium phosphates (BCP) may serve as off-the-shelf alternatives for iliac crest-derived autologous bone in alveolar cleft reconstructions. To add osteoinductivity to the osteoconductive BCPs to achieve similar regenerative capacity as autologous bone, a locally harvested buccal fat pad will be mechanically fractionated to generate microfragmented fat (MFAT), which has been shown to have high regenerative capacity due to high pericyte and mesenchymal stem cell content and a preserved perivascular niche.

OBJECTIVE

Our primary objectives will be to assess the feasibility and safety of the BCP-MFAT combination. The secondary objective will be efficacy, which will be evaluated using radiographic imaging and histological and histomorphometric evaluation of biopsies taken 6 months postoperatively, concomitant with dental implant placement.

METHODS

Eight patients with alveolar cleft (≥15 years) will be included in this prospective, nonblinded, first-in-human clinical study. MFAT will be prepared intraoperatively from the patient's own buccal fat pad. Regular blood tests and physical examinations will be conducted, and any adverse events (AEs) or serious EAs (SAEs) will be meticulously recorded. Radiographic imaging will be performed prior to surgery and at regular intervals after reconstruction of the alveolar cleft with the BCP-MFAT combination. Biopsies obtained after 6 months with a trephine drill used to prepare the implantation site will be assessed with histological and histomorphometric analyses after methylmethacrylate embedding and sectioning.

RESULTS

The primary outcome parameter will be safety after 6 months' follow-up, as monitored closely using possible occurrences of SAEs based on radiographic imaging, blood tests, and physical examinations. For efficacy, radiographic imaging will be used for clinical grading of the bone construct using the Bergland scale. In addition, bone parameters such as bone volume, osteoid volume, graft volume, and number of osteoclasts will be histomorphometrically quantified. Recruitment started in November 2019, and the trial is currently in the follow-up stage. This protocol's current version is 1.0, dated September 15, 2019.

CONCLUSIONS

In this first-in-human study, not only safety but also the histologically and radiographically assessed regenerative potential of the BCP-MFAT combination will be evaluated in an alveolar cleft model. When an SAE occurs, it will be concluded that the BCP-MFAT combination is not yet safe in the current setting. Regarding AEs, if they do not occur at a higher frequency than that in patients treated with standard care (autologous bone) or can be resolved by noninvasive conventional methods (eg, with analgesics or antibiotics), the BCP-MFAT combination will be considered safe. In all other cases, the BCP-MFAT combination will not yet be considered safe.

TRIAL REGISTRATION

Indonesia Clinical Trial Registry INA-EW74C1N; https://tinyurl.com/28tnrr64.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42371.

Alveolar Bone Grafting in Unilateral Cleft Lip and Palate: Impact of Timing on Palatal Shape

Alveolar bone grafting (ABG) is a critical surgical intervention in patients with a cleft of the alveolus, aimed at reconstructing the alveolar ridge to facilitate proper eruption, periodontal support, and alignment of adjacent permanent teeth. The optimal timing for ABG remains debated, with late secondary ABG between the ages of 9 and 11 being widely adopted. This study compared the palatal shapes of 28 children at a mean age of 9.5 years (SD = 0.7) who underwent early secondary ABG at a mean age of 2.1 years (SD = 0.6) or 33 children at a mean age of 10.8 years (SD = 1.5) who underwent late secondary ABG at a mean age of 8.6 years (SD = 1.3) to 60 non-cleft controls at a mean age of 8.6 years (SD = 1.2). The palatal shapes were captured with 239 landmarks digitized on the palate on a digital model. Utilizing geometric morphometric methods, i.e., generalized Procrustes superimpositions, principal component analysis, and permutation tests, we assessed the impact of ABG timing on palatal morphology. The first five principal components (PCs) explained 64.1% of the total shape variability: PC1 = 26.1%; PC2 = 12%; PC3 = 11.9%; PC4 = 7.8%; and PC5 = 6.4%. The Procrustes distance between both cleft groups and the control group was more than twice as large as the Procrustes distance between the early ABG and late ABG groups. Nonetheless, all intergroup differences were statistically significant. Our findings suggest that early ABG has a limited negative effect on palatal shape, providing comparable outcomes to late ABG. The study highlights the potential suitability of early ABG, challenging conventional practices and encouraging further exploration into its long-term effects on maxillary growth.

Influence of osseous structure characteristics of unilateral alveolar cleft on outcomes of alveolar bone grafting: a retrospective study

BACKGROUND

To enhance the success rate of alveolar bone grafting, it is crucial to identify the factors that may influence the postoperative bone formation. This study aimed to investigate the impact of various osseous structure characteristics of alveolar clefts on the survival ratio of autogenous cancellous bone particle grafts.

METHODS

A retrospective study was conducted on 60 patients who underwent surgery performed by the same surgeon between 2016 and 2022. Two researchers measured and recorded the bone defect volume (DV), postoperative bone formation volume at 1 year, contact area between the graft and the bone surface within the cleft (S), cleft width (CW), osseous occlusion relationships, and presence of a cleft palate and initial bone bridge within the cleft for each patient. Pearson correlation analysis, Spearman's correlation analysis, and multiple linear regression analysis were performed.

RESULTS

The analysis results revealed statistical correlations between DV, CW, ratio of S to DV, cleft palate, initial bone bridge presence, and occlusion relationships with the survival rate. Multiple linear regression analysis showed that initial bone bridge and occlusion relationships affected the graft survival rate.

CONCLUSIONS

Based on the presence of initial bone bridges and occlusions, we can make a rough estimate of the postoperative bone formation outcome in patients. However, the underlying mechanisms by which these two factors influence the bone formation require further investigation. In addition, preoperative orthodontic treatment to improve occlusal relationships may improve the postoperative bone formation outcomes in alveolar bone grafting.

Exome sequencing improves genetic diagnosis of congenital orofacial clefts

Objective: This retrospective study aims to evaluate the utility of exome sequencing (ES) in identifying genetic causes of congenital orofacial clefts (OFCs) in fetuses with or without other structural abnormalities, and to further explore congenital OFCs genetic causes. Methods: The study enrolled 107 singleton pregnancies diagnosed with fetal OFCs between January 2016 and May 2022, and categorized them into two groups: isolated cleft lip and/or palate (CL/CP) and syndromic CL/CP. Cases with positive karyotyping and chromosomal microarray analysis results were excluded. Whole-exome sequencing was performed on eligible fetuses and their parents. Monogenic variants identified by ES and perinatal outcomes were recorded and evaluated during postnatal follow-up. Results: Clinically significant variants were identified in 11.2% (12/107) of fetuses, with no significant difference in detection rate between the isolated CL/CP group and the syndromic CL/CP group (8/83, 9.6% vs. 4/24, 16.7%, p = 0.553). Additionally, sixteen (16/107, 15.0%) fetuses had variants of uncertain significance. We identified 12 clinically significant variations that correlated with clinical phenotypes in 11 genes from 12 fetuses, with CHD7 being the most frequently implicated gene (n = 2). Furthermore, we observed a significant difference in termination rates and survival rates between the isolated CL/CP and syndromic CL/CP groups (41.0% vs. 70.8% and 56.6% vs. 20.8%, p < 0.05 for both). Conclusion: Based on our findings, it is clear that ES provides a significant increase in diagnostic yield for the molecular diagnosis of congenital OFCs, thereby substantially improving the existing prenatal diagnostic capabilities. This study also sheds light on seven novel pathogenic variants, broadening our understanding of the genetic underpinnings of OFCs and expanding the disease spectrums of relevant genes.

Higher maternal age is associated with higher occurrence of cleft lip/palate in neonates under intensive care

Aim: To assess the prevalence of cleft lip and/or cleft palate (CL/P) and associated variables in neonates admitted to neonatal intensive care units (ICU). Methods: Medical charts for neonates born and admitted to the ICU between 2012 and 2018 were reviewed. Obstetric and neonatal variables were collected by a trained researcher. In the case group, all neonates with CL/P were included. The control group was formed by matching sex, prematurity and month of birth using random number generation. Neonates with congenital malformations were excluded from the control group. Adjusted logistic regression was used (p<0.05). Results: The prevalence of CL/P was 0.43% (n=15). Five cases were excluded, as pairing was not possible. Twenty neonates were included in the control group. In the final multivariate model, CL/P was only associated with increased maternal age. For each year of increase in maternal age, neonates had a 35.2% higher chance of presenting CL/P (95% confidence interval: 1.021–1.792). Conclusions: Higher maternal age was associated with higher occurrence of CL/P in neonates admitted to the ICU. No other neonatal or maternal independent variables were associated with CL/P. Due to missing data, interpretation of study results must be approached with caution.

Characterization of Bacterial Differences Induced by Cleft-Palate-Related Spatial Heterogeneity

Background: Cleft palate (CP) patients have a higher prevalence of oral and respiratory tract bacterial infections than the general population. Nevertheless, characteristics of bacterial differences induced by CP-related anatomical heterogeneity are unknown. Methods: In this study, we systematically described the characteristics of bacteria in the oral and nasal niches in healthy children, CP children, healthy adolescents, CP adolescents, and postoperative adolescents by 454-pyrosequencing technology (V3−V6) to determine bacterial differences induced by CP. Results: Due to the CP-induced variations in spatial structure, the early establishment of microecology in CP children was different from that in healthy children. Nasal bacterial composition showed greater changes than in the saliva. Moreover, such discrepancy also appeared in CP and postoperative adolescents who had even undergone surgery > 10 years previously. Interestingly, we found by Lefse analysis that part of bacterial biomarkers in the nasal cavity of CP subjects was common oral flora, suggesting bacterial translocation between the oral and nasal niches. Therefore, we defined the oral−nasal translocation bacteria as O-N bac. By comparing multiple groups, we took the intersection sets of O-N bacs selected from CP children, CP adolescents, and postoperative adolescents as TS O-N bacs with time−character, including Streptococcus, Gemella, Alloprevotella, Neisseria, Rothia, Actinomyces, and Veillonella. These bacteria were at the core of the nasal bacterial network in CP subjects, and some were related to infectious diseases. Conclusions: CP would lead to significant and long-term differences in oral and nasal flora. TS O-N bacs migrating from the oral to the nasal might be the key stone causing nasal flora dysbiosis in the CP patients.

Cleft lip and palate: the psychological burden of affected parents during the first three years of their children's lives

The surgical treatment of cleft lip and palate (CLP) has been well described in the literature. Nevertheless, little is known about the psychological burden of affected parents. The aim of this study was to investigate the psychological burden in parents of children with CLP within the first 3 years of the children's lives. A standardized questionnaire (Parenting Stress Index, PSI) was administered to 33 parents of children with CLP to evaluate their psychological burden. The corresponding interview was conducted independent of any operative procedure during the yearly routine CLP consultation. Each participant's stress profile was assessed and compared with the average values of parents with non-cleft children. Psychological stress was substantially increased in all participants when compared to the parents of healthy children. This result was highly significant (P < 0.001). Parent depression (P < 0.001) and child-related requirements (P < 0.001) were the most critical subscales in the stress profile. Overall, the child-related burden was greater than the parent-related burden. These results indicate that parents of children with CLP have a higher level of psychological stress than parents of non-cleft children. This psychological stress might be reduced if addressed by specialist clinical psychologists in cleft-treating centres.

Secondary bone grafting for alveolar clefts: surgical timing, graft materials, and evaluation methods

Alveolar cleft belongs to the spectrum of cleft lip and/or palate, affecting 75% of cleft lip/palate patients. The goals of alveolar cleft treatment are stabilizing the maxillary arch, separating the nasal and oral cavities, and providing bony support for both erupting teeth and the nasal base via the piriform aperture. Secondary alveolar bone grafting is a well-established treatment option for alveolar cleft. Secondary alveolar bone grafting is performed during the period of mixed dentition using autologous bone from various donor sites. There are several issues relevant to maximizing the success of secondary alveolar bone grafting, including the surgical timing, graft material, and surgical technique. In this study, we reviewed issues related to surgical timing, graft materials, and evaluation methods in secondary alveolar bone grafting.Abbreviations: ABG, alveolar bone grafting; CBCT, cone-beam computed tomography; DBM, demineralized bone matrix; GPP, gingivoperiosteoplasty; rhBMP, recombinant human bone morphogenetic protein; 2D, two dimensional; 3D, three dimensional

Extensive Gingivoperiosteoplasty Versus Secondary Alveolar Bone Grafting in Patients With Complete Bilateral Cleft Lip and Palate During the Mixed Dentition Period: A Retrospective Outcome Analysis

BACKGROUND

The concept of gingivoperiosteoplasty (GPP) in the mixed dentition stage as compared with secondary alveolar bone grafting (ABG) in management of alveolar cleft has not been much discussed upon. The authors present the experience with extensive GPP and ABG in the mixed dentition stage in complete bilateral alveolar cleft cases.

METHODS

A retrospective review of nonsyndromic patients with complete bilateral alveolar cleft operated on with either GPP or ABG (iliac crest) in the mixed dentition stage with at least 1-year follow-up was performed. Dental occlusal radiographs were evaluated for level of bone gain using Bergland and Witherow scales. Statistical evaluation of clinical success and procedure-related complications was conducted using χ2 test and odds ratio.

RESULTS

Twenty-four patients in the GPP group and 20 in the ABG group were comparatively studied. Clinical success rate as indicated by Bergland scales I and II (87.5% in GPP vs 82.5% in ABG; P = 0.731), complication rate (20.83% in GPP vs 30% in ABG; P = 0.484), and status of canine eruption showed no significant differences in clinical outcomes in both groups.

CONCLUSIONS

The technique of extensive GPP as described by authors shows equal efficacy to secondary ABG for management of bilateral alveolar clefts during the mixed dentition period.

Local delivery of FTY720 induces neutrophil activation through chemokine signaling in an oronasal fistula model

Purpose

Cleft palate repair surgeries lack a regenerative reconstructive option and, in many cases, develop complications including oronasal fistula (ONF). Our group has developed a novel murine phenocopy of ONF to study the oral cavity wound healing program. Using this model, our team previously identified that delivery of FTY720 on a nanofiber scaffold had a unique immunomodulatory effect directing macrophages and monocytes into a pro-regenerative state during ONF healing. Here, the objective of this study was to determine the effects of local biomaterial-based FTY720 delivery in the ONF model on the early bulk gene expression and neutrophil phenotypic response within the regenerating tissue.

Methods

Using a mouse model of ONF formation, a palate defect was created and was treated with FTY720 nanofiber scaffolds or (blank) vehicle control nanofibers. At 1 and 3 days post-implantation, ONF oral mucosal tissue from the defect region was collected for RNA sequencing analysis or flow cytometry. For the RNA-seq expression profiling, intracellular pathways were assessed using the KEGG Pathway database and Gene Ontology (GO) Terms enrichment interactive graph. To assess the effects of FTY720 on different neutrophil subpopulations, flow cytometry data was analyzed using pseudotime analysis based on Spanning-tree Progression Analysis of Density-normalized Events (SPADE).

Results

RNA sequencing analysis of palate mucosa injured tissue identified 669 genes that were differentially expressed (DE) during the first 3 days of ONF wound healing after local delivery of FTY720, including multiple genes in the sphingolipid signaling pathway. Evaluation of the DE genes at the KEGG Pathway database also identified the inflammatory immune response pathways (chemokine signaling, cytokine-cytokine receptor interaction, and leukocyte transendothelial migration), and the Gene Ontology enrichment analysis identified neutrophil chemotaxis and migration terms. SPADE dendrograms of CD11b⁺Ly6G⁺ neutrophils at both day 1 and day 3 post-injury showed significantly distinct subpopulations of neutrophils in oral mucosal defect tissue from the FTY720 scaffold treatment group compared to the vehicle control group (blank). Increased expression of CD88 and Vav1, among other genes, were found and staining of the ONF area demonstrated increased VAV1 staining in FTY720‐treated healing oral mucosa.

Conclusion

Treatment of oral mucosal defects using FTY720 scaffolds is a promising new immunotherapy to improve healing outcomes and reducing ONF formation during cleft palate surgical repair. Local delivery of FTY720 nanofiber scaffolds during ONF healing significantly shifted early gene transcription associated with immune cell recruitment and modulation of the immune microenvironment results in distinct neutrophil subpopulations in the oral mucosal defect tissue that provides a critical shift toward pro-regenerative immune signaling.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40883-021-00208-z.

Oral Rehabilitation of Bilateral Cleft Lip and Palate Patient with Simultaneous LeFort I Osteotomy and Zygomatic Implants: A Case Report

The aim of this study is to evaluate Le Fort I Osteotomy and zygomatic implantation without any graft placement for management of a cleft lip and palate patient. This case report describes oral rehabilitation of a 33-year-old patient with bilateral cleft lip-palate and oronasal fistula and atrophic pre-maxilla. As treatment, the patient received simultaneous Le Fort I osteotomy, palatoplasty and two zygomatic implant insertions. The prosthetic superstructure included zygomatic implant-supported removable hybrid prosthesis on bar locator and metal-ceramic fixed bridges in the posterior region. As conclusion, this protocol can be promising for management of patients with cleft lip-palate and malocclusion.

The Challenge of 3D Bioprinting of Composite Natural Polymers PLA/Bioglass: Trends and Benefits in Cleft Palate Surgery

Cleft lip and palate is the fourth most common congenital malformation. Its prevalence is about 1 in 750 to 1 in 2000 live births. The consequences of this malformation are major: maxillary growth deficit, unaesthetic appearance, phonation disorders, difficulty in eating, and psycho-social disorders. Cleft palate repair establishes the division between the oral and nasal cavities. The alveolar bone graft is a key step. Different sites of autogenous bone harvesting are used, the most common being the iliac crest. Nevertheless, the large number of complications associated with harvesting has led to the use of substitute biomaterials. Bioactive glasses, discovered in 1969, are a group of synthetic silica-based materials with bone-bonding properties. Although 45S5 granular composition is commonly used in bone surgery to repair critical defects, it is only rarely used in the repair of cleft palates because this galenic form is only moderately adapted. However, advances in bone tissue engineering allow the shaping of three-dimensional scaffolds, which support colonization by host cells. Recent advances in computer-aided design/computer-aided manufacturing (CAD/CAM) have even led to the 3D printing of scaffolds combining 45S5 bioglass with a natural and biocompatible poly-lactic acid matrix. The shape of the parts is customized and adapted to the particular shape of the critical bone defects. The objective of this literature review is to highlight the particularities of alveolar defects subsequent to facial clefts, then to detail the characteristics of the materials and technologies used to elaborate 3D matrices by bioprinting. Finally, we will explore research directions regarding their use in reconstructive surgery of cleft palates.

Efficiency of advanced-PRF usage in the treatment of alveolar cleft with iliac bone graft: A retrospective study

The aim of this study was to evaluate the efficiency of a new alveolar bone grafting protocol using advanced-PRF (a-PRF) by comparing the volumes of newly formed bone after a bone graft combining autogenous iliac crest bone with either PRF or a-PRF. Patients presenting with unilateral or a bilateral alveolar cleft were included retrospectively in two groups: one group was grafted using cancellous iliac crest bone with PRF (PRF group), whereas for the other group the same procedure was followed using a-PRF (a-PRF group). CBCT scans were performed 3 months preoperatively and 6 months postoperatively. The volume of newly formed bone was measured by subtracting the postoperative cleft volume from the preoperative cleft volume. The mean volume of newly formed bone was compared between the two groups using Student's t-test. Twenty-four patients were included, with 12 allocated to each group. Forty-eight CBCT scans were analyzed. The mean volume of newly formed bone was 0.29 (±0.09) cm³ in the a-PRF group, versus 0.20 (±0.08) cm³ in the PRF group (Student's t-test, p = 0.024). The percentage of newly formed bone was 60.4 (±10.4) % in the a-PRF group versus 51.4 (±18.4) % in the PRF group (Student's t-test, p = 0.165). Our study demonstrated improved bone regeneration in the a-PRF group. While bearing in mind the limitations of this study, the a-PRF procedure should be adopted in cleft bone grafting whenever possible.

Innovative Molecular and Cellular Therapeutics in Cleft Palate Tissue Engineering

Clefts of the lip and/or palate are the most prevalent orofacial birth defects occurring in about 1:700 live human births worldwide. Early postnatal surgical interventions are extensive and staged to bring about optimal growth and fusion of palatal shelves. Severe cleft defects pose a challenge to correct with surgery alone, resulting in complications and sequelae requiring life-long, multidisciplinary care. Advances made in materials science innovation, including scaffold-based delivery systems for precision tissue engineering, now offer new avenues for stimulating bone formation at the site of surgical correction for palatal clefts. In this study, we review the present scientific literature on key developmental events that can go awry in palate development and the common surgical practices and challenges faced in correcting cleft defects. How key osteoinductive pathways implicated in palatogenesis inform the design and optimization of constructs for cleft palate correction is discussed within the context of translation to humans. Finally, we highlight new osteogenic agents and innovative delivery systems with the potential to be adopted in engineering-based therapeutic approaches for the correction of palatal defects. Impact statement Tissue-engineered scaffolds supplemented with osteogenic growth factors have attractive, largely unexplored possibilities to modulate molecular signaling networks relevant to driving palatogenesis in the context of congenital anomalies (e.g., cleft palate). Constructs that address this need may obviate current use of autologous bone grafts, thereby avoiding donor-site morbidity and other regenerative challenges in patients afflicted with palatal clefts. Combinations of biomaterials and drug delivery of diverse regenerative cues and biologics are currently transforming strategies exploited by engineers, scientists, and clinicians for palatal cleft repair.

Molecular Diagnostics and In Utero Therapeutics for Orofacial Clefts

Orofacial clefts and their management impose a substantial burden on patients, on their families, and on the health system. Under the current standard of care, affected patients are subjected to a lifelong journey of corrective surgeries and multidisciplinary management to replace bone and soft tissues, as well as restore esthetics and physiologic functions while restoring self-esteem and psychological health. Hence, a better understanding of the dynamic interplay of molecular signaling pathways at critical phases of palate development is necessary to pioneer novel prenatal interventions. Such pathways include transforming growth factor-β (Tgfβ), sonic hedgehog (Shh), wingless-integrated site (Wnt)/β-catenin, bone morphogenetic protein (Bmp), and fibroblast growth factor (Fgf) and its associated receptors, among others. Here, we summarize commonly used surgical methods used to correct cleft defects postnatally. We also review the advances made in prenatal diagnostics of clefts through imaging and genomics and the various in utero surgical corrections that have been attempted thus far. An overview of how key mediators of signaling that drive palatogenesis are emphasized in the context of the framework and rationale for the development and testing of therapeutics in animal model systems and in humans is provided. The pros and cons of in utero therapies that can potentially restore molecular homeostasis needed for the proper growth and fusion of palatal shelves are presented. The theme advanced throughout this review is the need to develop preclinical molecular therapies that could ultimately be translated into human trials that can correct orofacial clefts at earlier stages of development.

Incidence of Secondary Lip Correction for Children With Unilateral Cleft Lip: A Single-Center Retrospective Study

BACKGROUND

Numerous reports have described the incidence of secondary lip correction for patients with cleft lip (CL), and this incidence broadly varies among centers. The purpose of this study was to determine this revision rate for a reasonably large number of patients in our center and identify the clinical factors that contribute to the revision rate.

METHODS

A retrospective chart review was conducted for all infants with unilateral CL with or without cleft palate who underwent primary cheiloplasty at our cleft center from 2006 to 2012. Four surgeons were in charge of almost all operations. We investigated how many children underwent lip revisions by the end of 2017.

RESULTS

In total, 490 infants underwent primary lip repair, and 47 underwent revision surgery by the age of 8 years. Half of them (24 children) underwent revisions at the age of 5 or 6 years. There was no significant difference in the revision rate by sex or cleft side. The revision rate in children with CL only tended to be lower than that in children with alveolar cleft or cleft palate, but it was not significantly associated with the cleft type. The revision rate ranged from 2.8% to 15.2% among surgeons.

CONCLUSIONS

The overall revision rate was 9.6%, which is relatively lower than that in other cleft centers. However, the repair technique and cleft care program should not be evaluated using the revision rate only. Various factors, including surgeons' preference, contribute to the indications for revision, and these factors can change with age. We plan to follow up the patients until our completion of the cleft care program and report the final revision rate.

New Technique for Closure of Alveolar Cleft With Umbilical Cord Stem Cells

This article presents the case of a newly born female patient with a cleft of the primary palate (alveolar cleft), with an in utero diagnosis of the described cleft, from whom umbilical cord stem cells are obtained and cryopreserved. The patient is managed with nasoalveolar molding, and at 5 months of age, she is taken to surgery for cheiloplasty and gingivoperiostioplasty with umbilical cord stem cells. A radiographic and CT follow-up is carried out on the described cleft.