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

Mandibular Distraction Osteogenesis in Children and Adolescents: A Clinical and Radiographic Research Using Cone-Beam Computed Tomography

AIM

The aim of this cross-sectional study was to evaluate, via cone-beam computed tomography, the long-term postoperative outcome in children treated with mandibular distraction osteogenesis.

MATERIALS AND METHODS

All young patients treated with mandibular distraction osteogenesis (MDO), during a 16-year period, at the University Department of Oral and Maxillofacial Surgery of a Pediatric Hospital, were recalled, and various clinical and radiographic parameters were recorded.

RESULTS

Eleven patients were included: 5 with hemifacial microsomia (HFM) and 6 with mandibular micrognathia. In all cases, MDO had been successful in regular follow-up and decannulation, soon after MDO, was achieved in all tracheostomy cases. The long-term result in cases of HFM was found stable, functionally and esthetically accepted, although less satisfactory than in regular follow-up; in micrognathia patients, relapse of different degrees was registered in 4 of 6 cases, without any need for tracheostomy though. Detailed and accurate information was obtained by cone-beam computed tomography (CBCT). The shape of the regenerated bone was irregular in HFM cases and relatively normal in the micrognathia cases. Quality of the regenerated bone was normal in all patients. The irregular shape registered in HFM cases did not compromise a safe orthognathic operation.

CONCLUSIONS

Distraction osteogenesis remains an early treatment choice in cases of mandibular deformities. Long-term findings showed that there is a degree of relapse with growth, which was more obvious in mandibular micrognathia cases. Computed tomography contributes to detailed evaluation of changes at the distraction site.

Evaluation of Secondary Alveolar Bone Grafting for Unilateral Complete Cleft Alveolus: A Retrospective Cone Beam Computed Tomography-Based Study

Background: In patients with cleft lip and palate (CLP), secondary alveolar bone grafting (SABG) with particulate cancellous bone marrow (PCBM) is recommended. Objective: To compare bone graft outcomes in patients with unilateral CLP, when SABG is completed before or after canine tooth eruption (ACE or BCE), as measured by cone beam computed tomography (CBCT). Methods: Patients were allocated into two cohorts, ACE and BCE. The outcomes were evaluated using CBCT, followed by univariate and multifactorial analyses. Results: A total of 468 patients (age 11.61 ± 4.03 years; male/female 288/180) were analyzed, including 282 in the BCE group (9.41 ± 1.59 years, 175/107) and 186 in the ACE group (14.95 ± 4.31 years, 113/73). Although 5-level assessment revealed no significant difference in clinical success rate (>4 points) between the BCE and ACE groups (53.90% vs. 47.85%, p = 0.20), BCE group showed significantly higher rate of bone bridges formation (73.05% vs. 62.90%, p = 0.02), which can be attributed to variations in orthodontic participation and follow-up time. Independent predictors of graft failure were wide cleft, severe oronasal fistula, no palatal bone wall, and insufficient PCBM filling (p < 0.01). Conclusions: SABG should be performed before canine eruption with more aggressive PCBM filling and oral fistula management.

Postoperative Radiologic Imaging in Secondary Alveolar Bone Grafting for Cleft Lip and Palate: A Systematic Review and Meta-Analysis

INTRODUCTION

Radiographs (XRs), computed tomography (CT) scans, and cone-beam CT (CBCT) scans are utilized for assessment of secondary alveolar bone graft (SABG) in patients with cleft lip and palate (CLP). However, the optimal choice for imaging modality remains unclear. This study compares the image fidelity and safety profile for XR, CT, and CBCT in the assessment of patients with CLP who have undergone SABG.

METHODS

Articles from MEDLINE and Elsevier Embase were screened. The primary outcome was graft success rate. Secondary outcomes were percent-by-volume of graft maintained and patient safety, defined by radiation exposure. A random effects model was used to calculate the pooled outcomes for each imaging modality. Chi-squared analysis was used to compare pooled outcomes between different imaging modalities.

RESULTS

Of the 149 articles identified initially, 14 were included. Computed tomography exhibited a significantly higher image fidelity demonstrated by a lower graft success rate (62.0%) compared with both XR (72.6%, P<0.01) and CBCT (69.8%, P<0.01). Cone-beam CT had the lowest reported percent-by-volume of graft maintained (32.1%). Computed tomography had a higher mean radiation dosage (39.7 milligray) than what has been reported for both XR and CBCT.

CONCLUSION

Computed tomography demonstrated lower graft success rates than both XR and CBCT, possibly indicating a higher image fidelity. However, compared with CBCT, CT may have a higher radiation exposure. Randomized trials and longitudinal studies are necessary to perform a direct comparison between CT and CBCT and to correlate the image fidelity of these modalities with clinical outcomes.

Evaluation of maxillary alveolar ridge formation and ridge continuity after secondary alveolar bone grafting using cancellous and cortico-cancellous bone graft in unilateral cleft alveolus using cone beam computed tomographic scan - a randomized controlled trial

PURPOSE

The aim of present study was to compare and evaluate the maxillary alveolar ridge formation and ridge continuity using cancellous and corticocanellous bone graft harvested from anterior iliac crest for complete secondary unilateral cleft alveolus defects.

MATERIAL AND METHOD

All patients were randomized into two groups for secondary alveolar bone grafting. Group I (n = 10) patients treated with cancellous particulate bone graft and group II (n = 10) patients treated with cortico-cancellous block graft. Maxillary alveolar ridge bone formation was assessed with the help of cone beam computed tomography (CBCT) scan using Planmeca Romexis Viewer 5.0 software. Maxillary alveolar ridge continuity was assessed with axial section of CBCT scan and clinical occlusal photograph. Preoperative CBCT scan and occlusal photographs were compared with post-op 6-month CBCT scan and occlusal photographs.

RESULT

The mean preoperative volume of cleft defect in group I was 4.2576 cm3 whereas in group II it was 4.2268 cm3. The mean postoperative bone bridge formation after 6 months in group I was 4.055 cm3 whereas in group II it was 3.8103 cm3. Preoperative and 6-month postoperative axial sections of CBCT scans were compared and 100% maxillary alveolar ridge continuity was achieved in both groups. The preoperative and postoperative occlusal photographs of both the groups were compared and showed accurate bone and well aligned maxillary alveolar ridge formation in all patients.

CONCLUSION

The present study concluded that maxillary alveolar ridge formation rate is less in cortico-cancellous iliac crest block graft compared to cancellous iliac crest particulate graft, but is equally good as cancellous bone graft.

CLINICAL TRIAL REGISTRATION NO

(REF/2020/09/031605)/ CTRI/ 2020/09/028001.

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

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

Alveolar cleft reconstruction utilizing a particulate autogenous tooth graft and a novel split-thickness papilla curtain flap - A retrospective study

During secondary alveolar cleft grafting, the use of autogenous cancellous bone harvested from the iliac crest is still considered the gold standard. Due to the risk of donor-site morbidity and excessive graft resorption, alternative grafting materials (e.g. intraoral bone, xenografts) have been tested. Autogenous tooth bone graft (ATB) is a novel material derived from extracted teeth. ATB has successfully been used in pre-prosthetic and periodontal surgery for hard-tissue reconstruction. Seven patients with unilateral cleft lip and palate were treated with ATB, using their own deciduous teeth for grafting. Defects were accessed utilizing a novel split-thickness papilla curtain flap. Cone-beam computed tomography scans were taken prior to and 3 months following cleft surgery to assess graft integration, graft stability, and the volume of the newly formed hard tissues. Hard-tissue gain, as measured at the 3-month follow-up, averaged 0.65 cm3 ± 0.26 cm3. Results showed acceptable graft integration and stability at the 3-month follow-up, with no adverse effects or excessive resorption of the graft. The use of ATB might be a feasible alternative for alveolar cleft grafting. However, long-term studies using a large sample size are required to derive further conclusions.

A Survey of Bone Grafting Practice Patterns in North American Cleft Surgeons

INTRODUCTION

Alveolar bone grafting aims to restore bony continuity of the alveolus and provide optimal periodontal support for teeth adjacent to the cleft. We created a survey of cleft surgeons to assess the current standard of care regarding this procedure.

METHODS

A multiple choice survey was implemented using Qualtrics software and emailed to a list of 708 surgeons from the ACPA membership directory. Correlation between various provider factors and treatment practices was assessed with Fisher's exact test and likelihood ratio tests.

RESULTS

The response rate was 17.5%. Eighty-seven percent of providers preferred to perform grafts prior to secondary canine eruption while 10% favored before central incisor eruption. Eighty-one percent favored palatal expansion prior to bone grafting. Wide variability existed regarding the time to initiate postoperative orthodontics; 43% waited 4 to 6 months. Sixty-four percent of surgeons now utilize cone beam CT to assess graft take. The majority of respondents utilized cancellous bone autograft (92%) from the anterior iliac crest (97%) as graft material. Seventy percent used three or more modalities for post-operative pain control management. Early career surgeons (0-5 years) appeared more likely to use non-autologous materials (p < .01) for grafting.

CONCLUSION

Alveolar bone grafting prior to secondary canine eruption remains the most common strategy but other protocols are employed. Surgeons utilize multiple modalities for radiographic evaluation and most often use autologous cancellous bone as the primary grafting material. There is no true consensus on the perioperative timing and sequencing of orthodontic manipulation while principles of multimodal perioperative pain control appear widely accepted.

Evaluating SWAG and Its Validity When Compared to 3D Imagery of Secondarily Grafted Cleft Sites

OBJECTIVE

To test validity of 2D Standardized Way to Assess Grafts (SWAG) ratings to assess 3D outcomes of bone grafting (ABG).

PATIENTS

43 patients (34 UCLP, 9 BCLP) with non-syndromic complete clefts, bone-grafted at mean age 9yrs/3mos, with available post-graft occlusal radiographs and cone beam computed tomography (CBCT) (taken mean 4yrs/9mos post-ABG).

MAIN OUTCOME MEASURES

2D occlusal radiographs rated twice using SWAG by 6 calibrated raters. 12 scores were averaged and converted to a percentage reflecting bone-fill. Weighted Kappas were assessed for SWAG reliability. 3D cleft-site bone volume was calculated by 1 rater using ITK-SNAP. 13 cleft sites were re-measured by the 'one rater' for 3D reliability using Intraclass Correlation Coefficient (ICC). 2D versus 3D ratings were compared using paired t-test, independent samples t-test, Bland-Altman and Linear Regression. Significance level was P = .5.

RESULTS

2D reliability was 0.724 (intra-rater) and 0.546 (inter-rater). 3D reliability was 0.986. Bland-Altman plot comparing 2D vs 3D showed for 45 of 47 graft-sites were within 2 SD's. Mean % bone-fill was 64.11% with 2D and 69.06% with 3D (mean difference = 4.95%) that was a non-significant difference in both t-tests. Regression showed a statistically significant relation between the two methods (r2 = 0.46; P = .0001).

CONCLUSION

2D SWAG systematically and non-significantly underestimated bone-fill. There was a significant correlation between 2D/3D methods. Bland-Altman analysis illustrated the similarity of the two methods. For comparisons of group (cleft treatment Centers') bone grafting outcomes, the 2D method may suffice as a proxy for the 3D method. However, with individual variation up to 40% in 2D estimates of actual 3D volume, 2D SWAG method cannot be used in place of 3D images.

β-Tricalcium Phosphate as Alveolar Bone Grafting in Cleft Lip/Palate: A Systematic Review

The aim of this systematic review is to describe and identify the prospects of β-Tricalcium Phosphate (β-TCP) as an alveolar bone grafting (ABG) material in cleft lip/palate (CL/P) or alveolar bone cleft defects. A systematic review protocol based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020) was drafted. The literature search was conducted using MEDLINE/PubMed, Web of Science/ISI Web of Knowledge, Scopus, and the Cochrane Library, with English as the inclusion criterion and no publication year limits. The keywords yielded a total of 5824 publications. After removing duplicates and non-English articles, there were 3196 suitable articles available for evaluation. Subsequently, 1315 studies remained after reviewing titles and abstracts. Furthermore, 85 full articles were assessed for eligibility. After reading the complete texts of those papers, 20 were eventually selected that matched the inclusion requirements. Thirteen out of the twenty studies included in this systematic review were deemed to have a low risk of bias; one had a high risk of bias; and six had a moderate risk of bias due to not reporting randomization. β-TCP, when used as an ABG material, is biocompatible, visible, practical, offers a less invasive procedure, and does not interfere with orthodontic treatment. Synthetic β-TCP for ABG can be an alternative to autologous bone grafts under certain terms and conditions. The efficacy of β-TCP for ABG in CL/P or alveolar bone cleft defects can be enhanced through a tissue engineering approach that combines β-TCP with growth factors, mesenchymal stem cells, or other graft materials, along with modifications to β-TCP's physical properties.

Evaluation of Alveolar Bone Reconstruction In Clefts With Early Or Late Secondary Bone Grafting: Use Of The 3d Kamperos score

There is still no consensus on the optimal age for alveolar grafting. In order to decide on the success of this graft, the best known radiographic assessments lacks precision. Kamperos recently proposed a 3D CBCT score that simultaneously assesses alveolar bone height and thickness, as well as the nasal floor level. The aim of this study was to apply this new score and compare it between an early secondary alveolar grafting « ESAG » (4-7 y) and a late secondary alveolar grafting « LSAG » (8-11 y) surgery group. A total of 32 cases of ESAG and 17 of LSAG were analysed. On 3D imaging, the median age of ESAGs was 10 years and 15 years for LSAGs. In the ESAGs, 78% of the permanents canines were not on the arch compared to 18% in the LSAGs. In both groups, the reconstruction of the nasal floor was very adequate but the height and thickness appeared less good in the ESAGs. The final score was higher in LSAG (Chi2, P < 0.005). The analysis of the alveolar bone with the Kamperos score is accurate and relevant but it should preferably be performed in the permanent dentition phase. This is because the area of rhizalysis of the primary teeth and the follicular sac of the erupting permanent teeth influence the presence of effective bone.

Secondary alveolar cleft grafting using autogenous mineralized plasmatic matrix (MPM) versus cancellous bone particles derived from anterior iliac crest

OBJECTIVE

The essential concern of alveolar cleft grafting in patients of cleft lip and palate at the mixed dentition phase is to gain bone within the cleft area that provides closure of the oronasal communication with continuous and stable maxilla for future cleft teeth eruption or implantation. This study aimed to compare the effectiveness of mineralized plasmatic matrix (MPM) versus cancellous bone particles harvested from anterior iliac crest in secondary alveolar cleft grafting.

PATIENTS AND METHODS

This prospective randomized controlled trial was conducted on ten patients with unilateral complete alveolar cleft requiring cleft reconstruction. Patients were randomly divided into two equal groups; group (1) included 5 patients who received particulate cancellous bone derived from anterior iliac crest (control group) and group (2) included 5 patients who received MPM graft prepared from cancellous bone derived from anterior iliac crest (study group). All patients received CBCT preoperatively, immediately postoperatively and after 6 months. On the CBCT, graft's volume, labio-palatal width, and height were measured and compared.

RESULTS

The outcome of the studied patients 6 months postoperatively showed that the control group had significant decrease in the graft volume, labio-palatal width, and height compared to the study group.

CONCLUSION

MPM allowed for the integration of bone graft particles inside a fibrin network, which offers positional stability of the bone particles, thus preserving their shape with subsequent "in situ" immobilization of the graft components. This conclusion was reflected positively in terms of maintained graft volume, width, and height compared to that of the control group.

CLINICAL RELEVANCE

MPM allowed for maintenance of grafted ridge volume, width, and height.

A Three-Dimensional Scale for the Qualitative and Quantitative Assessments of Secondary Alveolar Bone Grafting (SABG) in Unilateral Cleft Lip and Palate Patients Using Cone-Beam Computed Tomography (CBCT)

Background The objective of our study was to derive an objective assessment scale for three-dimensional (3D) qualitative and quantitative evaluation of secondary alveolar bone grafting (SABG) using cone-bone computed tomography (CBCT) in patients with unilateral cleft lip and palate (UCLP).

Methods CBCT scans for pre- and 3-month post-SABG were reviewed for bone volume, height, width, and density of the bony bridge formed in the cleft defect in 20 patients with UCLP. Basic descriptive and principal component analysis was used to extract the various sub-components of the scale. Spearman's correlation was used to check the validity of the scale, and intra-class coefficient (ICC) and Cronbach's α were calculated to establish the reliability and retest applicability of the scale.

Results Each CBCT scan was assessed in five areas: cementoenamel junction (CEJ), root apex, root midpoint, 3 and 6 mm below CEJ, and tabulated in percentiles of 20, 25, 40, 50, 60, and 75 for all the parameters (bone volume, density, and width). These scores were validated when correlated to the scale given by Kamperos et al. Cronbach's α for the domains demonstrated acceptable to excellent internal consistency. The ICC showed good test–retest reliability having a range of scores from 0.89 to 0.94.

Conclusion The proposed scale for the 3D assessment of SABG in patients with UCLP provides gradation for the objective assessment of the bony bridge. This gradation enables the qualitative and quantitative assessments of the bony bridge, thus allowing each clinician to judge SABG more conclusively.

Clinical, volumetric and densitometric evaluation of tissue engineered constructs for secondary alveolar cleft reconstruction: A randomized clinical trial

The objective of this study was to assess the efficacy of tissue engineered (TE) constructs compared to the standard autogenous anterior iliac crest (AIC) bone graft in secondary maxillary alveolar cleft reconstruction. This clinical trial was registered on (clinical trials.gov); the trial registry number is: NCT03563495. Patients with unilateral alveolar clefts were allocated on the basis of simple randomization. Selected patients were randomly divided into two equal groups: the AIC group (control) received autogenous particulate bone graft from anterior iliac crest, whereas the TE group received tissue engineered construct. Assessment included the newly formed bone volume and density at the grafted cleft sites, which were measured immediately, 6 and 12 months postoperatively on axial computed tomograms. The study population included 10 patients; each group comprised 5 patients. There was no statistically significant difference between the 2 groups regarding the mean volume of the newly formed bone (p = 0.91 at 6 months, p = 0.994 at 1 year) and the mean density of the newly formed bone (p = 0.364 at 6 months, p = 0.073 at 1 year). However, there was a significant increase of TE graft density from 6 months to 1 year (p = 0.048). Within the limitations of the study it seems that the tissue engineered construct (collagen/osteogenically differentiated bone marrow-derived mesenchymal stem cells) might be an alternative to autogenous bone for unilateral secondary alveolar cleftgrafting.

Alveolar Volume Following Different Timings of Secondary Bone Grafting in Patients with Unilateral Cleft Lip and Palate. A Pilot Study

This study was intended to evaluate the relationship between secondary alveolar bone grafting (SABG) timing and the alveolar volume in patients with unilateral cleft lip and palate (UCLP). The material consisted of CTs of 35 patients (17 males, 18 females) with UCLP who underwent a one-stage primary cleft repair at a mean age of 8.4 months and SABG at different timings ranges of 1.8–18.8 years. The mean age at CT was 17.2 years. The relative coefficient (Ꞷ) which was independent from factors such as individual maxillary size, gender or age at the CT was introduced in order to compare volumes of the cleft-side in relation to the non-cleft-side alveolus. Pearson correlation coefficient r between Ꞷ coefficient and SABG timing was weak negative (r = −0.34, p = 0.045). The multiple regression analysis implied that the dependent variable-Ꞷ coefficient was associated with independent variables (cleft repair and SABG timings and age at CT) with r² = 0.228. Only patient’s age at SABG explained the dependent variable (p = 0.003). The study cautiously indicates a tendency to larger alveolar volume following earlier timing of SABG. Nevertheless, the further research on a larger group of patients should be performed before formulating any clinical indications.

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.

Regenerative Strategies in Cleft Palate: An Umbrella Review

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

Maxillofacial morphology in post-pubertal patients with unilateral cleft lip and palate following early vs. late secondary alveolar bone grafting

The study aimed at comparing maxillofacial morphology and burden of surgical treatment in post-pubertal patients with unilateral cleft lip and palate (UCLP) following early vs. late secondary alveolar bone grafting (SABG). In this retrospective study maxillofacial morphology was assessed on lateral cephalograms of skeletally matured patients with UCLP operated on consecutively in one center by the same method of one-stage primary cleft repair followed by SABG. Cephalometric analysis comprised 8 angular and 7 linear measurements. Maxillary growth restriction was evaluated by measuring SNA angle and Co-A and PNS-A distances. Five linear regression models with SNA, SNB, ANB, Co-A, and MP/SN as dependent variables and age at primary cleft repair, age at SABG, age at taking cephalogram, surgeon, and total number of surgical interventions as independent variables were also created. 135 patients were included in the study - 70 patients (47 males and 23 females) had early SABG (E-SABG group) and 65 patients (40 males and 25 females) had late SABG (L-SABG group). Mean age at bone grafting procedure was 2.7 years (range 1.5-5.9, SD 1.1) and 10.3 years (range 6.1-18.8, SD 3.2) in E-SABG and LSABG group respectively. The variables describing the degree of maxillary growth restriction - SNA, Co-A, and PNS-A - were comparable in both groups (p = 0.707, 0.116, and 0.932, respectively). Regression models demonstrated that independent variables were not associated with the values of SNA angle, SNB angle, ANB angle, MP/SN angle, and Co-A distance (p = 0.761, 0.088, 0.249, 0.380, and 0.363, respectively). The percentages of oronasal fistula repair, VPI repair, repeated SABG, upper lip correction, rhinoplasty, orthognathic surgery were 22.9, 7.1, 15.7, 24.3, 42.9, 2.9 in E-SABG group and 27.7, 7.7, 9.2, 36.9, 47.7, 3.1 in L-SABG group respectively. Mean number of all surgical interventions was 3.2 in E-SABG and 3.4 in L-SABG group, respectively (p = 0.271). Considering the comparable maxillofacial morphology and burden of surgical care in matured patients after early and late SABG, the choice of timing of bone grafting surgery could be left to the discretion of the surgeon.