Morbidity of iliac crest donor site following open bone harvesting in cleft lip and palate patients

Outcomes of Xenograft with Platelet-rich Fibrin versus Autogenous Bone in Alveolar Cleft Grafting

Background

The use of a suitable graft material helps with sufficient osseointegration. The aim of this study was to compare the clinical and radiographic outcomes of two types of alveolar bone graft materials, xenografts with platelet-rich fibrin (PRF) and autogenous grafts, in patients with alveolar clefts.

Methods

Thirty-six patients with alveolar clefts were enrolled in this study. Those patients were randomly divided into two groups: group A, where the autogenous iliac bone graft was used to fill the alveolar defect, and group B, where the xenograft with PRF was used to fill the alveolar defect. After 6 months of grafting, patients were assessed in terms of pain, duration of hospital stay, and donor site morbidity associated with iliac crest harvesting, while bone formation was evaluated radiographically using cone beam computed tomography.

Results

The results showed no statistical differences as regards baseline and perioperative data. Operative duration was significantly lower among xenograft with PRF patients. Both groups had comparable postoperative success scores, and total failure was reported in a total of three patients (one patient in group A and two patients in group B).

Conclusions

With no potential donor site morbidities, xenograft with PRF is an equivalent bone transplant replacement to the autologous iliac bone graft. Additionally, it is associated with a significant success rate, and a significant decrease in operative time and hospital stay. Many future studies are warranted to draw firm conclusions.

Analysis of perioperative autonomic nervous system activity to visualize stress in pediatric patients undergoing alveolar bone graft surgery

Perioperative stress in pediatric patients is often difficult to assess via interviews; thus, an objective measure to assess perioperative stress is needed. To visualize perioperative stress, we observed autonomic nervous system (ANS) activity, circulatory dynamics, and psychological status in pediatric patients undergoing alveolar bone grafting under general anesthesia. This prospective observational study included 40 patients aged 8-12 years who were scheduled for alveolar bone grafting in our hospital. ANS activity was analyzed using heart rate variability the day before surgery, during general anesthesia, 2 h postoperatively, 24 h postoperatively, and the day before discharge. ANS assessment included LF/HF (sympathetic nervous system activity) and HF (parasympathetic nervous system activity). Additionally, heart rate (HR), systolic blood pressure (SBP), face scale (FS) score were recorded. Data from 31 patients, excluding dropouts, were analyzed. The ratio of change to the preoperative value was compared. After surgery, the LF/HF, HR, SBP, and FS score significantly increased (P < 0.01) and HF significantly decreased (2 h postoperatively: P < 0.05, 24 h postoperatively, before discharge: P < 0.01). SBP recovered to preoperative values 24 h postoperatively, and HR and FS scores recovered to preoperative values before discharge. However, even before discharge, LF/HF remained significantly higher than preoperative values, and HF remained significantly lower than preoperative values (P < 0.01). Conclusion We observed perioperative stress from multiple perspectives. Circulatory dynamics and psychological status recovered by the day before discharge; however, ANS activity did not. Therefore, evaluating ANS activity may be useful in visualizing potential perioperative stress in pediatric patients.

Iliac Crest Bone Graft Harvest for Alveolar Cleft Repair: A Systematic Review Comparing Minimally Invasive Trephine and Conventional Open Techniques

Background: In the course of developing a standardized pathway for alveolar cleft repair, we conducted a systematic review comparing minimally invasive trephine with conventional open technique for iliac crest bone graft harvest in a pediatric population. Methods: A systematic review was conducted of studies comparing open with minimally invasive trephine techniques in pediatric populations undergoing alveolar cleft repair. Exclusion criteria included reviews, case series, editorials, abstracts, and those with adult-only populations. Data were compiled with outcome variables selected a priori. Results: Of 422 manuscripts screened, five met criteria. These comprised 257 patients (116 open, 141 trephine). Average age was 11 years. Patients undergoing trephine harvest had reduced length of stay (1.0-5.0 days trephine vs 1.25-5.4 days open), time to unassisted ambulation (16-46 hours vs 20-67 hours open), and less postoperative narcotic use (0.31 mg/kg vs 1.64 mg/kg IV morphine). Volume of cancellous bone was reported as 2.53 mL for open versus 1.22 mL for trephine in one study, and trephine graft was supplemented with demineralized bone in 54% of cases in another study. The use of anesthetic adjuncts was inconsistent but had a significant effect on postoperative pain and ambulation. Conclusions: Compared to open techniques, the minimally invasive trephine bone graft harvest is associated with a shorter time to discharge, slightly lower infection rates, and reduced opioid use. The possible benefits of trephine harvest must however be balanced against the risk of insufficient graft harvest. Finally, the choice of perioperative analgesic adjuncts significantly impacts patient outcomes regardless of the technique employed.

Surgical and prosthetic rehabilitation of siblings with Witkop tooth and nail syndrome using zygomatic implants: a familial case series of 3 patients with up to 15-year follow-up

Witkop tooth and nail syndrome is a rare, autosomal dominant type of ectodermal dysplasia that can have significant effects on dentition, including hypoplastic and malformed dentition and significantly atrophic maxillas. Endosseous implants have become one possible solution to replace missing teeth, although their use in areas where bone is sparse becomes challenging. Due to the severe atrophy of the maxillary alveolus, extensive preprosthetic surgeries including orthognathic surgery, extensive bone grafting, and sinus floor augmentations have been recommended prior to placement of endosseous dental implants. Although this treatment has shown favorable outcomes, it requires multiple surgical procedures, contributing to a prolonged treatment course and increased morbidity. An alternative treatment of atrophic maxillas in patients with ectodermal dysplasia includes the use of zygomatic implants. This familial case series discusses 3 siblings, all previously diagnosed with Witkop Syndrome, who underwent comprehensive preprosthetic surgery and prosthetic rehabilitation using zygomatic implants with a follow-up period up to 15 years.

Comparison of two preserved cartilage iliac crest cortical-cancellous bone blocks graft harvesting techniques in children: A prospective, double-blind, randomized clinical trial

PURPOSE

To compare donor-site morbidity for alveolar bone grafting results following cartilage-preserving outer and inner cortico-cancellous iliac crest (OCIC and ICIC) bone block grafting in children.

MATERIALS AND METHODS

Patients were randomly divided into two groups and prospectively reviewed. In the OCIC and ICIC groups, cortico-cancellous bone blocks were harvested at outer and inner iliac crest respectively. Patient characteristics and surgical parameters were compared; pain intensity and duration, lateral femoral cutaneous nerve (LFCN) injury, gait disturbance, scar and contour satisfaction were analysed postoperatively.

RESULTS

Forty-nine consecutive patients (OCIC, 24; ICIC, 25) were included. There were no significant differences in patient characteristics or donor-site surgical parameters. The mean pain score on the first post-operative day was significantly lower in the OCIC group (3.75±1.70) than in the ICIC group (5.20±2.08) (p=0.012). The pain duration was similar in the two groups (median: 5 days). Temporary LFCN injury only occurred in 3 patients in the ICIC group. Postoperatively, the duck and circle gaits were observed in the OCIC and ICIC groups, respectively. There were no significant differences in the claudication duration, scar and contour satisfaction between the groups.

CONCLUSION

OCIC bone graft harvesting is marginally advantageous in children due to less early postoperative donor-site pain and a lower risk of nerve damage.

It's Hip to Go Home: An Evaluation of Outpatient Alveolar Bone Grafting in Patients With Cleft Palate

INTRODUCTION

Secondary alveolar bone grafting (ABG) is a common procedure performed at cleft care centers used to fill the alveolar cleft. The advent of techniques such as minimally invasive trephine drill harvest and placement of continuous-infusion pain pumps at the donor site has made outpatient ABG an increasingly feasible and cost-effective procedure. However, enhanced recovery after surgery protocols to maximize pain control and recovery times for this patient population have not been well established.

METHODS

A retrospective single-institution review was conducted of pediatric patients with cleft palate who underwent iliac crest bone graft ABG at a large urban academic children's hospital from 2017 to 2022. Patient age, alveolar cleft repair laterality, pain scores, surgery duration, hospital LOS, readmissions, and re-operations within 30 days were examined.

RESULTS

Fifty-four patients met our inclusion criteria. Fifty patients (92.6%) received a pain pump during the operation. The median duration of surgery and LOS in the post-anesthesia care unit were 1.28 and 1.75 hours, respectively. Fifty-two patients (96.3%) were discharged on the same day as their surgery whereas 2 patients (3.7%) stayed in the hospital overnight. The median pain score at the time of discharge was 0 (interquartile range 0, 0). There were 6 (11.1%) minor complications including 5 pain pump malfunctions and 1 recipient site wound breakdown. There was 1 readmission (1.9%) for development of a surgical site infection at the hip and no re-operations within 30 days of surgery.

CONCLUSION

The described outpatient ABG protocol demonstrates effective postoperative pain control, short hospital LOS, and few complications requiring hospital readmission or reoperation.

Evaluation of a Granular Bone Substitute for Bone Regeneration Using an Optimized In Vivo Alveolar Cleft Model

Alveolar cleft is a common congenital deformity that requires surgical intervention, notably using autologous bone grafts in young children. Bone substitutes, in combination with mesenchymal stem cells (MSCs), have shown promise in the repair of these defects. This study aimed to evaluate the regenerative capabilities of a granular bone substitute using an optimized alveolar cleft model. Thirty-six rats underwent a surgical procedure for the creation of a defect filled with a fragment of silicone. After 5 weeks, the silicone was removed and the biomaterial, with or without Wharton's jelly MSCs, was put into the defect, except for the control group. The rats underwent μCT scans immediately and after 4 and 8 weeks. Analyses showed a statistically significant improvement in bone regeneration in the two treatment groups compared with control at weeks 4 and 8, both for bone volume (94.64% ± 10.71% and 91.33% ± 13.30%, vs. 76.09% ± 7.99%) and mineral density (96.13% ± 24.19% and 93.01% ± 27.04%, vs. 51.64% ± 16.51%), but without having fully healed. This study validates our optimized alveolar cleft model in rats, but further work is needed to allow for the use of this granular bone substitute in the treatment of bone defects.

Effect of body mass index on progressive bone mineral density in patients with cleft after secondary alveolar bone grafting

BACKGROUND

Although childhood obesity matters, the association between body mass index (BMI) and bone mineral density (BMD) progression in grafted tissue after secondary alveolar bone grafting (ABG) for children with cleft alveolus is scarcely studied. Accordingly, this study explored the influence of BMI on BMD progression after ABG.

METHODS

In total, 39 patients with cleft alveolus receiving ABG at the mixed dentition stage were enrolled. Patients were classified as underweight, normal weight, or overweight or obese according to age- and sex-adjusted BMI. BMD was measured in Hounsfield units (HU) from cone-beam computed tomography scans obtained 6 months (T1) and 2 years (T2) postoperatively. Adjusted BMD (HU_{grafted tissue}/HU_pogonion, BMD_a) was used for further analysis.

RESULTS

For underweight, normal-weight, and overweight or obese patients, BMD_aT1 values were 72.87%, 91.85%, and 92.89%, respectively (p = 0.727); BMD_aT2 values were 111.49%, 112.57%, and 113.10% (p = 0.828); and density enhancement rates were 29.24%, 24.61%, and 22.14% (p = 0.936). No significant correlation was observed between BMI and BMD_aT1, BMD_aT2, or density enhancement rates (p = 0.223, 0.156, and 0.972, respectively). For patients with BMI < 17 and ≥ 17 kg/m², BMD_aT1 values were 89.80% and 92.89%, respectively (p = 0.496); BMD_aT2 values were 111.49% and 113.10% (p = 0.216); and density enhancement rates were 23.06% and 26.39% (p = 0.573).

CONCLUSION

Patients with different BMI values had similar outcomes (BMD_aT1, BMD_aT2, or density enhancement rate) after our ABG procedure in the 2-year postoperative follow-up.

Does the Transversus Abdominis Plane Block Reduce Morbidity Following Iliac Crest Bone Harvest in Pediatric Patients With Alveolar Clefts?

OBJECTIVE

The purpose of this study is to determine whether a Transversus Abdominis Plane (TAP) block can reduce donor site morbidity among pediatric patients undergoing iliac crest bone grafting for repair of their alveolar cleft.

DESIGN

This retrospective cohort study was carried out at the Division of Dentistry at the Montreal Children's Hospital. Medical charts of patients who underwent alveolar cleft bone grafting between January 2011 and January 2021 were reviewed and they were divided into two groups, intraoperative TAP block and intraoperative local anesthesia infiltration (control group). The outcomes measured were patients' post-operative pain at the donor site, in-hospital narcotics requirements and length of stay.

RESULTS

A total of 66 patients were included. There were no significant differences in pain scale among the TAP group and control group [1.9 (SD 2.5) and 1.3 (SD 2.1), respectively (p = 0.23)]. The mean length of stay for both groups was 1 day. Interestingly, there was a significant higher proportion of patients who required in-hospital opioids (morphine) in the TAP block group when compared to the control group (p = 0.03).

CONCLUSIONS

The results of our study suggest there may be no role for a TAP block in reducing pain and improving opioid stewardship.

Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report

Aim and objective

This case report aims to describe the management of alveolar cleft defect by iliac crest secondary bone grafting.

Background

The secondary alveolar bone grafting performed during the mixed dentition period is an essential module of modern-day rehabilitation of cleft lip and palate patients with alveolar defects. Iliac crest bone graft is a frequent secondary graft used and is technique sensitive.

Case description

A 12-year-old girl with alveolar cleft defect having problems with speech and regurgitation of fluids from nostril was presented and its management by a combination of iliac crest bone grafting and platelet-rich fibrin (PRF) was described.

Conclusion

One year recall radiograph showed successful bone augmentation with this secondary alveolar bone grafting along with application of platelet rich plasma (PRP).

Clinical significance

Osseous integration can be enhanced by PRP application over the graft which gives greater clinical outcome with less invasiveness.

How to cite this article

Vemagiri CT, Damera S, Pamidi VRC, et al. Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report. Int J Clin Pediatr Dent 2022;15(4):472-474.

"Improved Success Rate with Corticocancellous Block Compared to Cancellous-only Trephine Technique in Alveolar Bone Grafting from the Iliac Crest"

BACKGROUND

Alveolar bone grafting is an important component of cleft lip and palate treatment, with iliac crest as the most common donor site. Although studies have attempted to quantify alveolar bone graft resorption, few have directly compared the outcomes of graft techniques. This study compared the long-term success rates of corticocancellous block to trephine cancellous-only alveolar bone grafting from the iliac crest.

METHODS

A retrospective review of all cleft lip and palate patients undergoing alveolar bone grafting over 14 years was performed. Power analysis was performed to determine sample size. Data including patient demographics, surgical technique, need for repeat grafting, complications, length of hospitalization, and follow-up were collected. Statistical analyses of outcomes were performed based on initial graft technique.

RESULTS

A total of 106 initial operations met criteria, with 73 using trephine technique, 30 utilizing corticocancellous block, and 3 undergoing open cancellous harvest. The overall regraft rate was 40% with an average follow-up of 43.5 months. Patients with corticocancellous block grafting had significantly lower rates of repeat grafting compared to trephine technique (16.7% vs. 47.9%, p<0.001). There was no significant difference in complications rates or length of admission between treatment groups.

CONCLUSIONS

The use of corticocancellous block alveolar bone grafting demonstrated significantly higher success rates when compared to cancellous-only trephine techniques with no difference in complication rates. Although this must be weighed against the minor disadvantages of open iliac harvest, surgeons should consider incorporating en bloc corticocancellous bone to optimize outcomes in alveolar bone grafting.

Donor site morbidity in autologous bone grafting – A comparison between different techniques of anterior iliac crest bone harvesting: A prospective study

Background: The aim of this study is to compare morbidities at the donor site in autologous bone harvesting from an anterior iliac crest via the outer cortex, inner cortex and table splitting technique. Methods: The randomized, prospective and comparative study was conducted in 60 patients who were treated with bone grafting as a part of their treatment plan. Group A underwent the outer cortex technique (20 patients), Group B underwent the inner cortex technique (20 patients) and Group C underwent the table splitting technique (20 patients). The comparison of morbidities associated with various techniques of anterior iliac crest bone graft harvesting was done for a period of one year. Results: Most common morbidity observed was pain, measured by the visual analogue scale score (60/60, 100% of patients). The visual analogue scale score was significantly higher for the outer cortex group followed by the inner cortex group, and then the lowest score was for the table splitting group ( p < 0.05). Followed by numbness (40/60, 66%), least in the table splitting group and maximum in the outer cortex group ( p < 0.05). Next was abnormal gait, which was mostly seen in patients with the outer table method and least in the table split group ( p < 0.05). Other complications were infections (4), itching at the surgical site (3) and hematoma (1). There were no significant difference regarding scar satisfaction among comparison groups. Conclusion: we conclude that few differences do exist in harvest-site morbidities between different techniques used in our study. Overall, the most common morbidity observed were pain, numbness and abnormal gait. However, the table splitting group has the lowest morbidity, therefore bone harvesting by the table splitting appears to be a very good option.

Evaluation of the Proximal Tibia as a Donor Site of Cancellous Bone for Intraoral Grafting Procedures-A Retrospective Study

Background: Autogenous bone grafts remain the “gold standard” in maxillofacial reconstructive procedures. The objective of this study was to evaluate the proximal tibia as a donor site of cancellous bone for bone grafting procedures of the mandible on the basis of intraoperative parameters and clinical observations. Methods: The study was based on a medical record search of 40 patients who underwent surgical procedures because of benign pathological lesions of the jaws resulting in 3-wall bone defects of the mandible and qualified for surgical removal of the lesion with simultaneous bone grafting of the defect with autogenous cancellous bone harvested from the proximal tibia. Results: The use of the proximal tibia for bone grafting procedures enables large amounts of cancellous bone (15.09 cc in average) to be obtained. The procedure is characterized by a low risk of early and late complications, which include excessive bleeding, wound infection, lengthy healing time, scars, a loss of sensation around the scars, aching, a dip in bone, swelling and tenderness. Conclusions: The ability to obtain large amounts of cancellous bone and a low risk of intra- and postoperative complications make the proximal tibia an attractive donor site for the bone grafting procedures in maxillofacial surgery.

Pain management at iliac donor sites after grafting of alveolar clefts

The aim of this study was to answer the question: which analgesic protocol is most efficient and most effective in overcoming pain and promoting functional recovery after iliac bone grafting in cleft alveolus patients? A systematic review of the literature was performed. The population consisted of cleft lip and alveolus patients with or without cleft palate undergoing iliac crest bone grafting; the outcomes analysed were represented by the duration of hospital stay, subjective pain rating, and degree of impaired mobility. A total of 15 articles were selected for review. The following protocols were subject to comparison in this review: simple classic intravenous/per-oral analgesia, local anaesthetic infiltration in the donor site, anaesthetic-soaked sponge, neural blocks and continuous infusion at the donor site. The results of the included studies were individually reported identifying trends in the efficiency of the different pain-management techniques. Although hospital stay varied from same-day discharge to almost a week, other factors besides pain influenced this outcome. School was resumed after an average of 12.6 days and sport activities after maximum one month regardless of the used protocol. Even though the age of patients had a statistically significant influence on hospital stay durations, it did not determine the latter. The pain management protocols after iliac bone grafting of alveolar clefts selected for analysis have their advantages and drawbacks. All protocols seem effective meaning they reach adequacy in managing pain at the donor site. The efficiency of the protocols could not be assessed due to the lack of data and inconsistency in pain assessment scales. Further investigation through randomized controlled studies is required.

Cleft Alveolar Bone Graft Materials: Literature Review

INTRODUCTION

Since the early stages of alveolar bone grafting development, multiple types of materials have been used. Iliac cancellous bone graft (ICBG) remains the gold standard.

DESIGN/METHODS

A review of literature is conducted in order to describe the different bone filling possibilities, autologous or not, and to assess their effectiveness compared to ICBG. This review focused on studies reporting volumetric assessment of the alveolar cleft graft result (by computed tomography scan or cone beam computed tomography).

RESULTS

Grafting materials fall into 3 types: autologous bone grafts, ICBG supplementary material, and bone substitutes. Among autologous materials, no study showed the superiority of any other bone origin over iliac cancellous bone. Yet ICBG gives inconsistent results and presents donor site morbidity. Concerning supplementary material, only 3 studies could show a benefit of adding platelet-rich fibrin (1 study) or platelet-rich plasma (2 studies) to ICBG, which remains controversial in most studies. There is a lack of 3-dimensional (3D) assessment in most articles concerning the use of scaffolds. Only one study showed graft improvement when adding acellular dermal matrix to ICBG. Looking at bone substitutes highlights failures among bioceramics alone, side-effects with bone morphogenetic protein-2 composite materials, and difficulties in cell therapy setup. Studies assessing cell therapy-based substitutes show comparable efficacy with ICBG but remain too few.

CONCLUSION

This review highlights the lack of 3D assessments in the alveolar bone graft materials field. Nothing dethroned ICBG from its position as the gold standard treatment at this time.

The Effect of Single-Dose Bupivacaine on Postoperative Iliac Crest Graft Donor Site Pain

Background

Postoperative donor site pain remains a major source of morbidity following iliac crest bone graft harvesting (ICBGH).

Aim

The aim of this study was to investigate the effect of single-dose infiltration of bupivacaine on donor site pain following ICBGH.

Subjects and Methods

This study was a double-blind randomized controlled trial of 30 adult individuals that required an ICBG as part of the treatment for mandibular reconstruction. Individuals were divided into two groups, to receive a single-dose subcutaneous infiltration of either 0.25% bupivacaine or 0.9% normal saline at the iliac crest graft incision site following ICBGH. Length of incision at the ICBGH site, dimensions of harvested graft, time taken for the iliac crest harvest surgery, total daily dose of postoperative analgesics, pain from the ICBGH site as well as gait disturbance were recorded. Data were analyzed using SPSS version 17.0, and P < 0.05 was considered statistically significant.

Results

There was a progressive decrease in pain score from the 1^st to the 4^th postoperative day, with no significant difference between the two groups. There was no statistical difference between the two groups in terms of dynamic median pain score at the early postoperative period as well as at the 4^th and 12^th week postoperative period. The analgesic consumption between the two groups also did not show any significant difference.

Conclusion

Local injection of single dose of 0.25% bupivacaine did not offer additional benefit in the management of postoperative iliac crest donor site pain following ICBGH.

Effectiveness of presurgical orthodontics in cleft lip and palate patients with alveolar bone grafting: A systematic review

OBJECTIVE

Alveolar repair has become a routine part of treatment protocols for patients with non-syndromic cleft lip and/or palate, but there is no clear conclusion of whether the presurgical orthodontic treatment is necessary to alveolar bone grafting or not. The purpose was to determine the necessity of the presurgical orthodontics in cleft lip and palate patients.

MATERIALS AND METHODS

Electronic databases including PubMed, Ovid, Embase, Cochrane Library, Web of Knowledge, and China Biology Medicine disc (SinoMed) were searched. Only studies published in English or Chinese were included. The last search was updated on 1 May 2020. 1225 articles remaining after the exclusion of duplicates. Finally, there were 11 publications (five in English and six in Chinese) eligible for systematic review according to the previously established inclusion and exclusion criteria. A descriptive statistical method was used to present data. The methodological index for non-randomized studies (MINORS) was used to determine the risk of bias.

RESULT

Eleven articles were included in this review, of which seven publications were retrospective study and four articles were comparative study. The average success rate of reconstruction with the presurgical orthodontic treatment was approximately 70-97%, while the success rate of the non-presurgical orthodontics was 25-80%. The fixed and removable presurgical orthodontic methods were frequently performed, rather than a single treatment model. The incidence of the postoperative complications resulting from whether adopting the presurgical orthodontics was different from none to 75%.

CONCLUSION

There are a higher postoperative bone formation rate and a lower complication rate after ABG with presurgical orthodontics. However, more studies with high methodological quality and with a longer follow-up are needed to offer more safety for practitioners and patients regarding the surgical method selected to repair the cleft alveolar.

Effectiveness of corticocancellous bone graft in cleft lip and palate patients: A systematic review

OBJECTIVE

Both cancellous bone graft and corticocancellous bone graft are the most common grafts for repairing alveolar cleft, but there is no clear conclusion as to which method is beneficial to repair the alveolar cleft. The aim was to determine the effectiveness of corticocancellous bone graft in cleft lip and palate patients.

MATERIALS AND METHODS

Electronic databases including PubMed, Ovid, Embase, Cochrane Library, Web of Knowledge, and China Biology Medicine disc (SinoMed) were searched. Only studies published in English or Chinese were included. The last search was updated on 1 January 2020. 2638 articles remaining after the exclusion of duplicates. Finally, there were 16 publications (15 in English and 3 in Chinese) eligible for systematic review according to the previously established inclusion and exclusion criteria. A descriptive statistical method was used to present data. The methodological index for non-randomized studies (MINORS) was used to determine the risk of bias.

RESULT

Sixteen articles were included in this review, of which 15 publications were retrospective study and one was a comparative study. The average success rate of reconstruction with block bone was approximately 90.8%, while the success rate of the cancellous bone graft was about 85.3%. The incidence of wound dehiscence was approximately 10% to 16%, and infection is about 9% to 20%. The incidence of oronasal fistula resulting from severe bone resorption and infection was approximately 7.5% to 10.5%.

CONCLUSION

There is a higher bone formation rate of corticocancellous bone graft in patients with the alveolar cleft. However, more studies with high methodological quality and with a longer follow-up are needed to offer more safety for practitioners and patients regarding the surgical method selected to repair the cleft alveolar.

Comparison of minimally invasive versus conventional open harvesting technique for iliac bone graft in secondary alveolar bone grafting in cleft palate patients: a systematic review

This study evaluated and compared the donor site morbidity following minimally invasive and conventional open harvesting of iliac bone for secondary alveolar bone grafting in cleft palate patients. A thorough electronic search of PubMed, Google Scholar, EMBASE, and an institutional library and manual search of various journals was done; Inclusion criteria: 1) full-text articles using a minimally invasive or conventional open harvesting technique for iliac bone for secondary alveolar grafting in cleft palate patients and 2) articles published between January 1, 2001 and June 30, 2017 and Exclusion criteria: 1) articles published in languages other than English, 2) case reports, case series, animal studies, in vitro studies, and letters to the editor, and 3) full-text article unavailable even after writing to the authors. Preliminary screening of 274 studies excluded 223 studies for not meeting the eligibility criteria. Of the remaining 51 studies, 19 were removed for being duplicates. Of the remaining 32 studies, 15 were excluded after reading the abstract. Of the 17 studies that were left, 2 were excluded because they were in a language other than English, and 2 were excluded because the study group did not mention cleft palate patients. Thus, 13 studies providing results for a total of 654 patients were included in this qualitative synthesis. Minimally invasive bone graft harvest techniques are better than the conventional open iliac bone harvest method because they offer shorter operative time, decreased requirement for pain medications, less pain on discharge, and a shorter hospital stay.

Oral rehabilitation of a case with regional odontodysplasia using a regenerative approach-A case report and a review of literature

AIM

to investigate for the first time whether the regenerative approach can be used to rehabilitate a case with regional odontodysplasia (ROD). ROD is a rare, localized developmental anomaly of the dental tissues. Moreover, we review the various treatment protocols for ROD and compare them to the suggested regenerative protocol.

CASE REPORT

A 22-year-old female patient diagnosed with ROD in the upper left quadrant was presented to our clinic. Initially, the affected teeth were extracted and three implants were inserted. A combination of autologous bone marrow mononuclear cells (BMMNCs) seeded on a collagen sponge, nanohydroxyapatite, and autologous platelet-rich fibrin (PRF) was used to enhance bone regeneration in the defective area and around the inserted implants. After 9 months, bone regeneration and successful osteointegration around the inserted implants were achieved, permitting the insertion of a fourth implant. After an additional six months, a final fixed restoration was constructed.

CONCLUSION

The suggested regenerative approach provides a better treatment option for ROD patients to regenerate the lost bone, rehabilitate aesthetics, and restore normal function.

Gait Analysis of Patients Subjected to the Atrophic Mandible Augmentation with Iliac Bone Graft

In this study, we aimed to quantitatively monitor and describe the gait functions of patients, who underwent iliac crest bone grafting in atrophic jaw augmentation operation, by taking into account the alterations of gait parameters and muscle forces in the early recovery course. To do so, temporospatial and kinematic gait parameters of ten patients during pre- and postoperative periods were recorded, and forces of the gluteus medius, gluteus maximus, and iliacus muscles were calculated. Three postoperative periods were specified as one week (post-op1), two weeks (post-op2), and three weeks (post-op3) after the surgery. Restoring process of the gait patterns was comparatively evaluated by analyzing the gait parameters and muscle forces for pre- and postoperative periods. Temporospatial and kinematic parameters of post-op3 were closer to those obtained in pre-op than those in post-op1 and post-op2 (p < 0.05). Muscle forces calculated in post-op3 showed the best agreement with those in pre-op among the postoperative periods in terms of both magnitude and correlation (p < 0.05). In conclusion, the patients began to regain their preoperative gait characteristics from the second week after surgery, but complete recovery in gait was observed three weeks after the surgery.

A Multimodal Preemptive Analgesic Protocol for Alveolar Bone Graft Surgery: Decreased Pain, Hospital Stay, and Health Care Costs

OBJECTIVE

To evaluate postoperative pain, hospital length of stay (LOS), and associated costs of multiple perioperative analgesic strategies following alveolar bone grafting (ABG).

DESIGN

Retrospective comparative cohort study.

SETTING

Tertiary care pediatric hospital.

PATIENTS/PARTICIPANTS

Iliac crest bone graft (ICBG) harvest techniques: "Open Harvest" (n = 22), "Trephine Only" (n = 14), or "Trephine + Pain Pump" (n = 25).

INTERVENTION

The "Open Harvest" group underwent open ICBG harvest with 3-walled osteotomies. For the other 2 treatment groups, a trephine drill was used to harvest iliac crest bone with a ropivacaine infusion pump into the hip donor site ("Trephine + Pain Pump") or without ("Trephine Only"). Patients who underwent ABG with only cadaveric allograft were analyzed as a comparison group ("No Harvest").

MAIN OUTCOMES MEASURES

Outcomes were planned prior to data collection: maximum pain score, hospital LOS, and associated health care costs.

RESULTS

Maximum pain scores were significantly higher in the "Open Harvest" group (7.3/10) compared to "Trephine + Pain Pump" (1.8/10; P < .0001) and "No Harvest" groups (2.8/10; P < .01). Hospital LOS decreased from 2.4 days ("Open Harvest") to 0.5 days (Trephine + Pain Pump"; P < .0001). Twelve (48%) patients from "Trephine + Pain Pump" were discharged on the day of surgery. The "Trephine + Pain Pump" saved an estimated $5336 for a unilateral ABG and $7265 for a bilateral ABG compared to "Open Harvest."

CONCLUSIONS

The combined use of the trephine ICBG technique and ropivacaine infusion catheter effectively decreased pain, shortened hospital stay, and improved cost saving compared to patients who have undergone other methods of ICBG.

Use of the On-Q Pain Pump in Alveolar Bone Grafting: Effect on Hospit Length of Stay

Objective

Alveolar bone grafting (ABG) with iliac crest bone graft can be associated with significant pain at the donor site. The On-Q pain pump has been shown to be efficacious in treating postsurgical pain. The aim of this study was to compare the length of postoperative hospital stay in patients undergoing ABG who received the On-Q pain pump at the iliac crest donor site (On-Q+) with that of patients who did not receive the On-Q pain pump (On-Q-).

Design

A retrospective, cohort study, approved by institutional review board, was performed. Thirty-one consecutive patients in the On-Q- group were compared with 38 consecutive patients in the On-Q– group. The two cohorts were assessed for length of stay. Statistical analysis was performed using the Fisher exact probability test.

Setting

Tertiary care academic medical center.

Patients

Sixty-nine patients with cleft lip and/or cleft palate (CL/P) undergoing secondary ABG with iliac crest bone graft were operated on between May 1993 and January 2014.

Main Outcome Measure

Length of postoperative hospital stay.

Result

Mean length of stay in the On-Q– patients was 0.52 days versus 0.37 days for the On-Q– patients. This difference between the two cohorts was not statistically significant (P = .234).

Conclusion

Although there is a trend toward a shorter length of stay in our patients who received the On-Q pump, this finding was not statistically significant. Given the expense and additional burden of care associated with the device, we have become more selective in its utilization.

Comparison between peri-implant bone level changes of implants placed during and 3 months after iliac bone grafting

OBJECTIVE

The aim of this study was to compare the peri-implant bone level changes of implants placed during and 3 months after bone grafting from the iliac crest.

STUDY DESIGN

A total of 103 implants were placed: 42 during the grafting and 61 at 3 months after the grafting procedure. All patients were grafted with iliac bone from the anterosuperior iliac crest. Bone resorption was evaluated with cone beam computed tomography in all patients at their last control visit. Periodontal health was assessed via the gingival and plaque indices and pocket depths around the dental implants.

RESULTS

Mean bone resorption values at the buccal, lingual, mesial, and distal sides of the implants were 1.08 mm, 0.36 mm, 0.30 mm, and 0.25 mm, respectively, in the delayed group, and 1.87 mm, 1.25 mm, 0.92 mm, and 1.23 mm, respectively, in the simultaneous group; the differences between the groups were significant. There were no significant between-group differences in the gingival or plaque indices or pocket depths. The mean follow-up period was 29 months.

CONCLUSIONS

For reconstructing atrophic jaws, bone grafting from the iliac crest and implant placement after 3 months is a reliable technique with a high success rate and less bone resorption.

Evaluation of Donor Site Morbidity Associated with Iliac Crest Bone Harvest in Oral and Maxillofacial, Reconstructive Surgery

INTRODUCTION

Iliac crest is the most common donor site for autogenous bone grafting as cortical bone, cancellous bone or combination of both can be harvested in abundance depending upon the need. Ilium provides highest concentration of osteo-component cells and greater quality of bone with less morbidity.

AIM

The study was conducted to evaluate the donor site morbidity associated with autogenous iliac crest bone grafting for reconstruction in maxillofacial surgery.

MATERIALS AND METHODS

Around 12 patients, who had undergone iliac crest bone harvesting for various maxillofacial and reconstructive surgical procedures like cleft alveolus repair, malar augmentation, mandibular reconstruction following tumour resection and cyst enucleation and other surgical procedures performed in the Department of Oral and Maxillofacial Surgery, over a span of two years. The donor site was evaluated for the following factors: pain, neuropraxia, abnormal gait and scar evaluation.

RESULTS

None of the 12 patients had intraoperative complications like haemorrhage, damage to the muscles/ligaments, fracture of the ilium and damage to the acetabular fossa/femur head. Any major postoperative complications were also not recorded. Minor postoperative complications like pain, contour defect, walking difficulty were present, which gradually got resolved by the time of discharge.

CONCLUSION

Anterior iliac crest provides an adequate harvest of cancellous, corticocancellous or bicortical grafts for reconstruction of various osseous defects in the maxillofacial region with least morbidity and should be considered as a major reservoir of bone for bony reconstructive procedures.

Influence of Standardized Orientation on Patient Perception of Perioperative Care following Alveolar Cleft Repair: A Survey Based Study of Patients Treated in a Large Academic Medical Center

Objective

This study aims to better understand patient-reported outcomes for iliac bone grafting surgery for alveolar cleft repair and to determine how standardizing perioperative patient instruction affects patient-reported outcomes.

Design

Retrospective survey-based assessment of patients undergoing iliac bone grafting with and without hospital-based systems standardization.

Setting

Academic tertiary care hospital.

Patients

Of the 195 identified patients, 127 participated.

Interventions

Survey on pain and satisfaction regarding iliac bone grafting surgery.

Main Outcome Measures

Survey answers measured patient opinions about the surgery. Answers of the pre- and poststandardization patients were compared to determine the effect of standardizing patient instructions.

Results

Patients rated their satisfaction with the surgery and recovery a 4.5 and 4.4 out of 5, respectively. They rated their overall pain in the hospital a 5.5 out of 10 (4.9 in the mouth, 5.7 in the hip). Patients were discharged an average of 1.2 days after surgery and could return to normal daily activity in 6.1 days. Poststandardization patients were more likely to adhere to instructions regarding use of an antibacterial mouthrinse and a protective oral splint.

Conclusions

Patients were highly satisfied with the iliac bone grafting procedure and the recovery and reported only moderate levels of postoperative pain. Implementing standardized patient instructions may not affect patient satisfaction or pain severity, but it significantly increased patient adherence to physician instructions.

Evaluation of graft uptake from the iliac crest in secondary alveolar bone grafting: Bergland's criteria revisited

Back ground

The secondary alveolar grafting is an integral part in the management of alveolar cleft defect. Particulate cancellous bone and marrow (PCBM) graft obtained from iliac crest are considered as the gold standard.

Aim

Aim of the study was to evaluate the graft uptake clinically and radiologically using the Bergland's radiographic scale.

Material and methods

A longitudinal descriptive study was conducted on twenty patients of unilateral CLP in the age group of 6-13 years, presenting with residual/secondary alveolar cleft defect with unerupted maxillary lateral incisor/canine adjacent to the defect. Autologous PCBM graft obtained from iliac crest was used in all cases. Post operative clinical and radiological evaluation was carried out using the Bergland's radiographic scale at intervals of 1 week, 1 month and 6 months.

Data collection and result

Clinical evaluation consisted of assessment for infection, exposure of graft, rejection of graft, wound dehiscence and status of oronasal communication. A four-point Bergland's radiographic scale was used to compare the interdental height of the bone graft with unaffected side and categorized from grade I to IV. After six months, 6 cases were graded as grade I, 11 cases as grade II and 2 cases were grade III. Only one case deteriorated to grade IV which is considered as failure.

Summary and conclusion

Satisfactory results were obtained in 95% cases. Bergland's radiographic assessment scale is a valuable, easily available and inexpensive diagnostic tool to assess the condition of the grafted bone in SABG.

Chin bone graft for maxillary alveolar cleft: indications and limitations

BACKGROUND

Alveolar bone grafting (ABG) is an important step in the management of patients with cleft lip and palate. Choice of autogenous bone grafting is critical to achieve the goals of alveolar cleft bone grafting. This study was designed to determine which situations are suitable for obtaining bone from the chin in ABG.

MATERIALS AND METHODS

In a retrospective study, the alveolar clefts that had been bone-grafted from the chin bone were selected from the archived files of the Oral and Maxillofacial Department, Mashhad University of Medical Sciences in 2004 to 2012. The patients were recalled and postoperative panoramic and lateral cephalometry views were obtained.

RESULTS

Seventeen patients were included in this study, with 53% females and 70.5% unilateral maxillary alveolar clefts. The follow-up was from 2 to 6 years. The mean age of the patients at the time of surgery was 17 ± 3.8 years.

CONCLUSION

Harvesting bone from the chin is easy and safe, with low morbidity. Considering the fact that the volume of the harvested bone is low, especially in the presence of unerupted mandibular canine, autogenous chin bone is recommended for late ABG, especially in unilateral cases when the plan is to close the gap in the arch orthodontically while there is no need for lateral piriform augmentation.

Intracortical versus anteromedial approach for iliac crest bone harvesting in preprosthetic surgery: a randomized prospective clinical trial

PURPOSE

The aim of this study was evaluate the morbidity after anterior iliac crest bone harvesting by comparison of 2 approaches: medial and intracortical.

PATIENTS AND METHODS

Between April 2006 and February 2010, 73 consecutive subjects underwent anterior iliac crest bone harvesting. The sample was divided in 2 groups: 37 subjects treated with the medial approach and 36 with the intracortical approach. Patients were monitored during their hospital stay, considering the postoperative complications, the analgesic requirements, resumption of the ambulation, and length of stay. Postoperative controls were performed at 7, 14, and 30 days 6 and 12 months after surgery. A questionnaire on patient's satisfaction and complaints was released.

RESULTS

The 2 approaches resulted in significant statistical differences in 3 areas: the average time of operation, recovery of gait capabilities, and duration of the postsurgical pain were lower when intracortical approach was used.

DISCUSSION AND CONCLUSION

The low postsurgical morbidity can be related to the minimal muscular detachment, and the risk of fracture is reduced. Bone wax is not necessary for the hemostasis. We consider intracortical approach to be ideal in the case of selected transversal maxillary atrophies.

Donor site evaluation: anterior iliac crest following secondary alveolar bone grafting

INTRODUCTION

The use of autogenous bone graft for Secondary alveolar bone grafting is well established in the treatment of cleft lip and palate patients.

AIMS AND OBJECTIVES

To evaluate post-operative morbidity of anterior iliac crest graft after secondary alveolar bone grafting in cleft patients.

MATERIAL AND METHODS

Forty patients during the period from July 2008 to March 2013, who underwent secondary alveolar bone grafting by harvesting graft from anterior iliac crest in Mamata Dental Hospital, Khammam, Andhra Pradesh, India are included in the present study. Unilateral and bilateral cleft patients who had undergone secondary alveolar bone grafting (SABG) with anterior iliac crest as their donor site have been selected and post- operative complications from the surgery were evaluated with the help of a questionnaire which included pain, gait disturbances, numbness and scar problems (infection, irritation).

RESULTS

Patients who were operated gave maximum score for pain as 8 on visual analogue scale. No pain was observed in any of the cases after 8 days, gait disturbances were seen in all patients (limping) for 2-6 days, there was no post-operative numbness with all the patients returning to their routine in 6- 15 days and 90% of the patients gave a satisfied response towards scar.

CONCLUSION

From the results in our study the morbidity after harvesting bone from iliac crest was found to be moderate to low, which had minimal complications and were well tolerated and greater acceptance from the patient.

Morbidity associated with anterior iliac crest bone graft

OBJECTIVE

The aim of this retrospective study was to assess the morbidity of the harvest of the anterior iliac bone graft and the overall satisfaction rates in a group of patients who underwent harvesting of iliac crest bone graft.

PATIENTS AND METHODS

Patients who underwent iliac crest bone graft procedures from January 2002 to August 2009 were recalled and invited to answer a questionnaire about postoperative pain, sensory disturbance, functional limitations, and cosmetic appearance.

RESULTS

A total of 61 patients were included in this retrospective study. Seventeen patients (28%) reported postoperative pain. A patient reported an intraoperative hip fracture. Sensory disturbances were reported by 3 patients.

CONCLUSIONS

Anterior iliac crest can still be considered a favorable donor site for preprosthetic and cleft surgery. Given its relatively low morbidity rate, early ambulation, and hospital discharge, anterior iliac crest still remains the donor site of choice according to the authors.

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Continuous infusion of bupivacaine for pain control after anterior iliac crest bone grafting for alveolar cleft repair in children

OBJECTIVE

The purpose of this study was (1) to evaluate the analgesic efficacy of continuous infusion bupivacaine, (2) to evaluate the effects of the site-specific catheter infusion on operating room time, narcotic use, ambulatory status, and length of hospitalization, (3) to monitor for adverse outcomes, and (4) to assess patient/family acceptance.

DESIGN

Randomized, double-blinded, and prospective study of bupivacaine versus saline for pain control after anterior iliac crest bone grafting for alveolar cleft repair.

SETTING

University of Alabama at Birmingham.

PATIENTS

A total of 65 pediatric patients with alveolar cleft defects treated between 2006 and 2009.

INTERVENTIONS

Anterior iliac crest bone grafting for alveolar cleft repair with assignment to either a bupivacaine or a saline infusion group.

MAIN OUTCOME MEASURES

Physical examination, pain ratings, narcotic use, ambulatory status, operating room time, and length of hospital stay.

RESULTS

On the blinded physical exam, 71% in the bupivacaine infusion group and 42% in the saline infusion group were assessed as not experiencing pain at the surgical hip site. The experimental group used less narcotics compared with the control group. No significant differences were noted with operating room time, initial ambulatory status, or length of hospitalization (1.09 versus 1.12 days). Satisfaction and acceptance of the catheter treatment was universal.

CONCLUSIONS

These results suggest that postoperative infusion of bupivacaine may be efficacious for enhancing pain relief after bone harvest in pediatric patients and may enhance parental perceptions of postoperative care; however, this patient population is difficult to study accurately.

β-TCP versus autologous bone for repair of alveolar clefts in a goat model

OBJECTIVE

The aim of this study in goats was to test the hypothesis that a novel synthetic bone substitute beta tricalcium phosphate (β-TCP) can work as well as autologous bone harvested from the iliac crest for grafting and repair of alveolar clefts.

DESIGN

Ten adult Dutch milk goats (Capra hircus) were used in a split-mouth study design.

MAIN OUTCOME MEASURES

Volumetric histologic assessment of new bone formation and radiographic measurement of orthodontic movement of teeth in a formerly created alveolar cleft.

CONCLUSIONS

The synthetic bone substitute β-TCP was shown to result in bone healing similar to that of iliac crest bone. The surgical, orthodontic, and histologic results now warrant the testing of β-TCP in the human cleft situation.

Retrospective review of 99 patients with secondary alveolar cleft repair

PURPOSE

The purpose of the present review was to evaluate the protocol and technique used in a large population of patients with cleft lip and palate when secondary grafting is performed during the early mixed dentition stage, as determined by eruption of the central incisor. In the United States, most investigators have recommended alveolar grafting at the 9- to 11-year age range or before eruption of the permanent canines.

MATERIALS AND METHODS

An institutional review board-approved chart review of 99 patients undergoing alveolar cleft bone grafting during a 7-year period at a single institution was performed. Data were collected regarding demographics, operative time, length of hospitalization, follow-up time, complications, and additional procedures performed. The cases were divided by patient age into 2 groups: group 1, aged 6 to 8 years (n = 61); and group 2, aged 9 years and older (n = 38). Statistical analysis was performed for various comparisons in the study.

RESULTS

The average operative time for groups 1 and 2 was 86 and 103 minutes, respectively. The complication rate, length of stay, and follow-up time between the 2 groups was not statistically significant at the P = .05 significance level.

CONCLUSIONS

We recommend earlier bone grafting at or before the eruption of the central incisor, rather than delaying until the cuspid tooth root is 25% formed. We believe this will provide better bone support for the dentition, a decreased burden of treatment for the patient, and improved quality of life. Performing the procedure at this time can lead to decreased operative times, with comparable postoperative outcomes.