Primary osteoplasty using calvarian bone in patients with cleft lip, alveolus and palate

Long-Term Treatment Outcomes of Primary Alveolar Bone Grafts for Alveolar Clefts: A Qualitative Systematic Review

BACKGROUND

Alveolar bone grafting is utilized to manage alveolar clefts in patients with cleft lip and palate. However, the timing of bone grafting is variable with conflicting evidence supporting the use of primary alveolar bone grafting (PABG) in clinical practice.

PRIMARY AIM

To provide a qualitative systematic review analysis of long-term outcomes after PABG.

MATERIALS AND METHODS

A qualitative systematic review was performed following the Cochrane Handbook and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Summative findings were evaluated using Confidence in the Evidence from Reviews of Qualitative research to assess the quality of evidence supporting the findings.

RESULTS

After removing duplication, 2182 publications were identified, and 2131 were excluded after screening through titles and abstracts. Inclusion criteria for this study included patients who underwent PABG at 24 months of age or younger and a minimum of 5 year follow-up. Thirty-two publications met the inclusion criteria and were included for qualitative analysis. Primary outcome measures included cephalometric analysis, bone graft survival, occlusal analysis, hypomineralization, tooth eruption, radiograph analysis, and arch relationships. Four assessment themes were characterized from the systematic review: (1) bone graft survival, (2) craniofacial skeletal relationships, (3) occlusion and arch forms, and (4) recommendations for utilizing PABG in practice.

CONCLUSION

The reported systematic review provides evidence that performing PABG leads to poor long-term outcomes related to bone graft survival and maxillary growth restriction despite some reported positive outcomes.

[Alveoloplasty and the use of osteosynthesis material in the cleft lip palate]

OBJECTIVES

To compare the results of secondary alveoloplasty performed in one Hospital when osteosynthesis material was used and when the bone graft does not require this material, and relating them to factors such as gender and age.

MATERIAL AND METHODS

A retrospective study was conducted from the years 2014 to 2019 in this Hospital on the selected patients who met the inclusion criteria. Two periods of ages, period A: ages between 5-12 years (mixed secondary alveoloplasty) and period B: greater than 12 years (late secondary alveoloplasty). Autologous bone from the iliac crest or parietal calotte was used for the bone graft. The patients were divided into 2 groups: group I: patients with alveoloplasties that required osteosynthesis material. Group II: patients who did not require osteosynthesis material. Parameters evaluated: the success criteria for alveoloplasty were assessed according to the clinical parameters described by Precious. Alveoloplasty was successful if they met all the criteria of Precious in the year of intervention. Postoperative complications in both groups were evaluated. The statistical analysis was performed using the exact Fisher test for qualitative variables.

RESULTS

Alveoloplasty was successful in 89.4% of patients in group I, while it was 90.3% in group II. Alveoloplasty was successful in 87.5% of females compared to 91.17% of males. The intervention was a success in 91.48% of patients in group A, compared to 66.6% in group B. The osteosynthesis material in two patients of group I was not degraded in the annual assessment. There were no significant differences in any of the comparisons.

CONCLUSIONS

The use of osteosynthesis material does not alter the integration of the bone graft in patients that undergo alveoloplasty. Factors such as gender or age do not influence the results of the interventions.

Evaluation of the presence of MMP-2, TIMP-2, BMP2/4, and TGFβ3 in the facial tissue of children with cleft lip and palate

Cleft lip and palate (CLP) is the most common defect affecting the face. The treatment consists of surgical reconstruction of the anatomical structures of the cleft. Part of the surgical treatment is reconstruction of the alveolar bone by means of autogenic bone grafting (osteoplasty). This study aimed to evaluate the levels of expression of extracellular matrix remodeling factors in the facial tissue of children with a complete unilateral (CU) and a complete bilateral (CB) CLP to assess whether the wound healing process is adequate. Twenty-two CLP patients were enrolled in this study. Tissue samples were collected during alveolar osteoplasty for unilateral (n = 12) or bilateral (n = 10) cleft palate, (age range from 6 years 8 months to 12 years 2 months). Control material was obtained in the case of tooth extraction (age range from 6 years 9 months to 14 years 5 months). Immunohistochemistry was used to assess the levels of matrix metalloproteinase-2 (MMP-2), tissue inhibitor of metalloproteinase-2 (TIMP-2), bone morphogenetic proteins 2 and 4 (BMP2/4), and transforming growth factor β3 (TGFβ3). Numbers of positively stained cells were graded semi-quantitatively. Data were analysed using the Kraskel-Wallis rank test and the Bonferroni correction. The total number of MMP2-positive cells was significantly lower in the CBCLP and in the control group than in the CUCLP (p < 0.001 after the Bonferroni correction). The total number of TIMP2-positive cells was significantly higher in the CUCLP than in the CBCLP and in the control group (p < 0.001; p < 0.003 after the Bonferroni correction). The overall number of BMP2/4, TGFβ3-positive cells was significantly higher in the CUCLP than in the CBCLP and in the control group (p < 0.001 after the Bonferroni correction). The decrease of the relative amount of statistically significant BMP2/4, TGFβ3, MMP-2, TIMP-2 containing bone cells in CBCLP patients identifies affected alveolar bone regeneration and remodeling process.

Does Platelet-Rich Fibrin Enhance Bone Quality and Quantity of Alveolar Cleft Reconstruction?

BACKGROUND

Recently, platelet-rich fibrin (PRF) was described as a second-generation platelet concentrate. PRF is known as a rich source of autologous cytokines and growth factors and is universally used for tissue regeneration in clinical medicine.

OBJECTIVE

The aim of the current study was to evaluate the effect of PRF on the quality and quantity of bone formation in unilateral maxillary alveolar cleft reconstruction.

PATIENTS AND METHODS

Twenty-four patients with unilateral alveolar cleft underwent bone reconstruction. Patients were randomly divided into two groups. Group A consisted of patients grafted with PRF combined with autogenous anterior iliac crest bone graft. Group B patients were grafted using autogenous bone graft alone (control group). Computed tomography was performed 6 months postoperatively to assess the quality and quantity of the newly formed bone.

RESULTS

The percentage of newly formed bone (quantity) in group A ranged from 79.74% to 88.4%, with a mean percentage of 82.6% ± 3.9%. In group B, the percentage of bone formation ranged from 60.3% to 76.4%, with a mean percentage of 68.38% ± 6.67%. There was a statistically significant increase in the percentage of newly formed bone in group A. The mean bone density (quality) of the newly formed bone was lower in group A than group B, but the difference was not statistically significant (P < .05).

CONCLUSIONS

PRF in combination with autogenous bone was beneficial in improving the volume of newly formed bone in alveolar cleft reconstruction and does not enhance bone density.

Is alveolar cleft reconstruction still controversial? (Review of literature)

Cleft lip and palate (CL/P) is a frequent congenital malformation that manifests in several varieties including unilateral or bilateral and complete or incomplete. Alveolar cleft reconstruction remains controversial with regard to timing, graft materials, surgical techniques, and methods of evaluation. Many studies have been conducted addressing these points to develop an acceptable universal protocol for managing CL/P. The primary goal of alveolar cleft reconstruction in CL/P patients is to provide a bony bridge at the cleft site that allows maxillary arch continuity, oronasal fistula repair, eruption of the permanent dentition into the newly formed bone, enhances nasal symmetry through providing alar base support, orthodontic movement and placement of osseointegrated implants when indicated. Other goals include improving speech, improvement of periodontal conditions, establishing better oral hygiene, and limiting growth disturbances. In order to rehabilitate oral function in CL/P patients alveolar bone grafting is necessary. Secondary bone grafting is the most widely accepted method for treating alveolar clefts. Autogenous bone graft is the primary source for reconstructing alveolar cleft defects and is currently the preferred grafting material.

Anatomical variation and morphology in the position of the palatine foramina in adult human skulls from Greece

OBJECTIVE

To investigate the anatomical variability of the palatine structures in Greek population.

MATERIAL AND METHODS

71 Greek adult dry human skulls were examined to detect the position of the greater palatine (GPF) and lesser palatine foramina (LPF) related to adjacent anatomical landmarks.

RESULTS

The perpendicular distance of the GPF to the midline sagittal suture was 1.53 cm and 0.3 cm from the inner border of the alveolar ridge. The mean distance from the posterior palatal border was consistent 0.46 cm on the right and 0.47 cm on the left side of the skulls. In the greater majority of the skulls (76.2%), the GPF were between proximal-distal surfaces of the 3rd maxillary molar. A single LPF was observed in 53.45% of the skulls, two LPF were observed in 31% of the skulls bilaterally and five LPF were rare (2.1%). The commonest position of LPF was at the junction of the palatine bone and the inner lamella of the pterygoid plate (71.9%).

CONCLUSION

Our results can help clinicians localize the palatine foramina in patients with and without maxillary molars and to predict the depth of a needle to anaesthetise the maxillary nerve with greater success when performing surgical procedures in the hard and soft palate.

Influence of lip closure on alveolar cleft width in patients with cleft lip and palate

Background

The influence of surgery on growth and stability after treatment in patients with cleft lip and palate are topics still under discussion. The aim of the present study was to investigate the influence of early lip closure on the width of the alveolar cleft using dental casts.

Methods

A total of 44 clefts were investigated using plaster casts, 30 unilateral and 7 bilateral clefts. All infants received a passive molding plate a few days after birth. The age at the time of closure of the lip was 2.1 month in average (range 1-6 months). Plaster casts were obtained at the following stages: shortly after birth, prior to lip closure, prior to soft palate closure. We determined the width of the alveolar cleft before lip closure and prior to soft palate closure measuring the alveolar cleft width from the most lateral point of the premaxilla/anterior segment to the most medial point of the smaller segment.

Results

After lip closure 15 clefts presented with a width of 0 mm, meaning that the mucosa of the segments was almost touching one another. 19 clefts showed a width of up to 2 mm and 10 clefts were still over 2 mm wide. This means a reduction of 0% in 5 clefts, of 1-50% in 6 clefts, of 51-99% in 19 clefts, and of 100% in 14 clefts.

Conclusions

Early lip closure reduces alveolar cleft width. In most cases our aim of a remaining cleft width of 2 mm or less can be achieved. These are promising conditions for primary alveolar bone grafting to restore the dental bony arch.