Alveolar cleft repair in adults using guided bone regeneration with mineralized allograft for dental implant site development: a report of 2 cases. J Oral Maxillofac Surg. 2009;67:1716-1722. [PMID: 19615587 DOI: 10.1016/j.joms.2009.04.012]

Alveolar cleft reconstruction using bone marrow aspirate concentrate and iliac cancellous bone: A 12-month randomized clinical study

OBJECTIVE

This study aimed to compare the bone density and volume in patients with alveolar cleft reconstructions utilizing bone marrow aspirate concentrate with iliac graft versus iliac graft alone.

MATERIAL AND METHODS

Thirty-six patients with unilateral alveolar cleft were randomly allocated into either an intervention group receiving an iliac bone graft mixed with bone marrow concentrate or a control group receiving an iliac bone graft. Cone beam CT was obtained preoperative, 6 and 12 months postoperatively to assess the bone density of the graft and bone volume of the alveolar defect, and then, the bone loss ratio was calculated.

RESULTS

Bone volume and bone density demonstrated a statistically significant increase in the intervention group at 6 and 12 months. In contrast, the bone loss ratio decreased significantly in the intervention group throughout the follow-up period.

CONCLUSION

A combination of bone marrow concentrate and iliac cancellous bone in alveolar cleft reconstruction may improve bone densities and volume in addition to decreasing graft loss rate.

CLINICAL SIGNIFICANCE

Using of bone marrow aspirate concentrate will decrease the amount of the graft needed and decrease the ratio of bone loss at the grafted site by the time. Trial registration ClinicalTrials.org ( NCT04414423 ) 4/6/2020.

Anterior Dental Implant in Grafted Cleft Alveolus: A Clinical Comparison Between Intramembranous and Endochondral Bone Graft

BACKGROUND

Alveolar bone graft is usually performed during the early mixed dentition phase, at the chronological age of 6 to 8 years old, to reconstruct the cleft alveolus. As the appropriate time for implant placement is after completion of full growth, it can result in a likelihood of resorption. The aim of this study is to compare the clinical outcomes of anterior dental implants with delayed bone grafting using iliac crest (endochondral) and mandibular ramus or symphysis (intramembranous) bone in adolescents to adulthood patients with cleft alveolus.

MATERIALS AND METHODS

This study included 10 patients with cleft alveolus who underwent delayed bone grafting with autogenous block bone and particulate cancellous bone and marrow (PCBM) from the mandibular ramus and symphysis with dental implant placement, and iliac crest. The success of the treatment was evaluated through clinical and radiographic examination including marginal bone loss measurement of the implants.

RESULTS

All patients underwent delayed bone grafting between the ages of 11 and 21.1 years (mean age: 15.1±4.3 y). The implant diameters ranged from 3.8 to 4.5 mm and the lengths ranged from 8.0 to 11.5 mm. All of the implants were integrated successfully and survived during the 3-year follow-up period.

CONCLUSIONS

Delayed bone grafting followed by implant placement showed long-term stability with satisfactory esthetic and functional rehabilitation. One of the main advantages of delayed bone grafting is to achieve adequate bone support for future dental implant placements with less bone resorption compared with those of primary, early secondary, and secondary bone grafting.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

The Use of Dual Energy X-Ray Bone Density Scan in Assessment of Alveolar Cleft Grafting Using Bone Marrow Stem Cells Concentrate/Platelet-Rich Fibrin Regenerative Technique

OBJECTIVES

To determine the densitometric quality of regenerated bone at the site of bone marrow and platelet-rich membrane grafting technique at unilateral alveolar cleft region using dual energy x-ray bone density scan (DEXA).

METHODS

The present prospective cohort study included 16 unilateral alveolar cleft patients who were selected randomly from the outpatient maxillofacial surgery clinic and suffered from unilateral alveolar cleft. Bone marrow aspirate and platelet-rich fibrin (PRF) (bone marrow stem cells + PRF) were used as the grafting material. Six months of follow-up have been conducted for all patients' including clinical and radiographic assessments with (DEXA scan).

RESULTS

Sixteen unilateral patients with a mean age of 12.56 ± 1.71 years were included in the sample and the majority of patients were females with a frequency of 56.2 percent. The current research revealed no infection or wound dehiscence. After surgery, the pain and edema scores were reasonable. Our findings showed that, after 6 months of regenerative graft, the average bone mineral density of the cleft side DEXA scan value was 1.56 ± 0.32 gm/cm2, compared to 1.51 ± 0.488 gm/cm2 on the normal side of the noncleft scan. There was no statistically significant difference in DEXA bone mineral content measurements between the cleft and standard sides (P = 0.461).

CONCLUSIONS

The bone marrow stem cells + PRF regenerative graft technique has been successfully integrated, and the DEXA scan approach for measuring regenerated grafted bone mineral content was found to be appropriate for simple and inexpensive follow-up of alveolar cleft lip patients.

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

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

Application of Hydroxycholesterols for Alveolar Cleft Osteoplasty in a Rodent Model

BACKGROUND

Bone morphogenetic proteins (BMPs) have played a central role in the regenerative therapies for bone reconstruction, including alveolar cleft and craniofacial surgery. However, the high cost and significant adverse effect of BMPs limit their broad application. Hydroxycholesterols, naturally occurring products of cholesterol oxidation, are a promising alternative to BMPs. The authors studied the osteogenic capability of hydroxycholesterols on human mesenchymal stem cells and the impact of hydroxycholesterols on a rodent alveolar cleft model.

METHODS

Human mesenchymal stem cells were treated with control medium or osteogenic medium with or without hydroxycholesterols. Evaluation of cellular osteogenic activity was performed. A critical-size alveolar cleft was created and one of the following treatment options was assigned randomly to each defect: collagen sponge incorporated with hydroxycholesterols, BMP-2, or no treatment. Bone regeneration was assessed by means of radiologic and histologic analyses and local inflammation in the cleft evaluated. Moreover, the role of the hedgehog signaling pathway in hydroxycholesterol-mediated osteogenesis was examined.

RESULTS

All cellular osteogenic activities were significantly increased on human mesenchymal stem cells treated with hydroxycholesterols relative to others. The alveolar cleft treated with collagen sponge with hydroxycholesterols and BMP-2 demonstrated robust bone regeneration. The hydroxycholesterol group revealed histologically complete bridging of the alveolar defect with architecturally mature new bone. The inflammatory responses were less in the hydroxycholesterol group compared with the BMP-2 group. Induction of hydroxycholesterol-mediated in vitro osteogenesis and in vivo bone regeneration were attenuated by hedgehog signaling inhibitor, implicating involvement of the hedgehog signaling pathway.

CONCLUSION

Hydroxycholesterols may represent a viable alternative to BMP-2 in bone tissue engineering for alveolar cleft.

Alveolar Cleft Reconstruction Using Different Grafting Techniques

BACKGROUND

Cleft lip and palate CLP is a frequent congenital malformation that manifests in several varieties including unilateral or bilateral anomalies due to either genetic or acquired causes. Alveolar cleft graft ACG remains controversial as regard timing, grafting materials and surgical techniques. The primary goal of alveolar cleft grafting in ACG patients is to provide an intact bony ridge at the cleft site to allow maxillary continuity for teeth eruption, proper orthodontic treatment for dental arch alignment, oronasal fistula closure and providing alar support for nasal symmetry.

AIM

This study aims to compare different grafting techniques to treat the alveolar cleft defect.

METHODS

This study included 24 cases divided into three groups of patients: Group A was treated with autogenous iliac crest bone; Group B was treated with nano calcium hydroxyapatite with collagen membrane and Group C was treated with tissue engineering method using bone marrow stem cells extract and PRF membrane.

RESULTS

According to clinical and radiographic examination measuring bone density in the CT preoperatively compared to six months postoperatively. Group C with bone marrow stem cells extract showed superior results among all followed by group B, while group A with autogenous iliac crest showed resorption in some cases and gave the least values, in addition to its drawbacks as regard donor site affection with pain & scar formation.

CONCLUSION

Bone substitutes as Nano calcium hydroxyapatite and bone marrow stem cells extract showed to be reliable methods for bone grafting than autogenous iliac crest.

Optimal Timing of Alveolar Cleft Bone Grafting for Maxillary Clefts in the Cleft Palate Population

PURPOSE

Timing of bone grafting for maxillary alveolar clefts is not standardized. Secondary bone grafting is often performed; however, consensus does not exist regarding use of chronologic versus dental age to guide treatment. Several authors suggest an early chronologic age is associated with greater success. Available literature was systematically reviewed for evidence for optimal timing for grafting maxillary alveolar clefts.

METHODS

PubMed, MEDLINE, and Cochrane Central Registrar of Controlled Trials databases were queried for manuscripts pertaining to maxillary alveolar cleft bone grafting. Inclusion criteria included manuscripts with level of evidence 4 or greater. Studies not using bone graft, lacking postoperative follow up, and clinical reports were excluded. Seventeen articles met criteria.

RESULTS

Nine manuscripts recommended grafting based on dental age prior to eruption of the permanent canines, while 8 recommended grafting between ages 7 to 12. The most commonly reported complication was wound dehiscence, followed by graft-site infection. Ten studies used perioperative treatment protocols, 8 of which included preoperative and/or postoperative orthodontia for maxillary expansion. Correlation between chronologic age and success was not significant, but trended towards greater success with increasing age.

CONCLUSION

Success of secondary grafting is high, but significant variability exists in the timing of grafting. Evidence is lacking to support specific chronologic age; rather, perioperative protocols, systematic surgical technique, and a multidisciplinary discussion are likely more substantial in achieving success, and may be confounders in studies where an early age at grafting appears associated with success. The timing of bone grafting for maxillary alveolar clefts would benefit from a prospective randomized study.

Applications of stem cells in orthodontics and dentofacial orthopedics: Current trends and future perspectives

A simple overview of daily orthodontic practice involves use of brackets, wires and elastomeric modules. However, investigating the underlying effect of orthodontic forces shows various molecular and cellular changes. Also, orthodontics is in close relation with dentofacial orthopedics which involves bone regeneration. In this review current and future applications of stem cells (SCs) in orthodontics and dentofacial orthopedics have been discussed. For craniofacial anomalies, SCs have been applied to regenerate hard tissue (such as treatment of alveolar cleft) and soft tissue (such as treatment of hemifacial macrosomia). Several attempts have been done to reconstruct impaired temporomandibular joint. Also, SCs with or without bone scaffolds and growth factors have been used to regenerate bone following distraction osteogenesis of mandibular bone or maxillary expansion. Current evidence shows that SCs also have potential to be used to regenerate infrabony alveolar defects and move the teeth into regenerated areas. Future application of SCs in orthodontics could involve accelerating tooth movement, regenerating resorbed roots and expanding tooth movement limitations. However, evidence supporting these roles is weak and further studies are required to evaluate the possibility of these ideas.

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

The goal of reconstruction of the alveolar cleft in patients with cleft lip and palate is to improve the quality of tissue, the structural stability, and increase the volume of bone. This study is a systematic review with meta-analysis of volumetric bony filling using autogenous bone and various tissue-engineered bone substitutes. We made an electronic search on MEDLINE, EMBASE, SCOPUS, WEB OF SCIENCE, "grey" publications (materials and research produced by organisations outside traditional channels for commercial or academic publishing and distribution), and relevant cross references according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported the outcomes of volumetric grafting were included in the meta-analysis. Of 1276 studies, 26 were included in the meta-analysis. Pooled analysis of 25 studies that used autogenous bone showed a significant reduction in the volume of the cleft equivalent to 62.0% bone fill (95% CI 54.3 to 69.6), in contrast to 10 studies that used a tissue-engineered material and reported bone filling of 68.7% (95% CI 54.5 to 82.8). The estimated sizes of pooled effects across studies showed that there was no significant difference between the two major intervention groups (p value 0.901). Our statistical analysis showed that autogenous bone grafts did not differ significantly from tissue-engineered materials in their ability to fill clefts. Systematic review registration: International Prospective Register of Systematic Reviews, PROSPERO (CRD42017065045).

Regenerative medicine in the treatment of alveolar cleft defect: A systematic review of the literature

Despite a possible risk of donor site morbidity, autogenous bone grafting is considered the gold standard treatment for human alveolar cleft defect. Tissue engineering methods have recently been investigated with the aim of minimizing donor site morbidities. Here we systematically review the various tissue engineering methods applied to human alveolar cleft defects. An electronic search was conducted in the PubMed database up to March 2014. Tissue engineering studies on human alveolar subjects were included, and experiments that did not report quality or quantity of new regenerated bone were excluded. Twenty human experiments were included in our review. Regenerative techniques for alveolar cleft bone reconstruction were divided into cell therapy, growth factor application, and a combination of both cell therapy and growth factor. Using these three regenerative methods, a wide range of new bone formation percentages were reported. Due to insufficient evidence and controlled clinical trials, the treatment efficacy of tissue engineering in alveolar cleft bone defects could not be determined. Well-designed controlled studies are needed so that detailed outcomes can be properly compared.

[Implant-borne prosthetic rehabilitation in patients with cleft lip and palate: A retrospective study on 43 patients]

INTRODUCTION

Implant-borne rehabilitation in cleft lip and palate patient are aimed to allow for good orofacial functions, stable occlusion, and adequate support for the naso-labial region. The goal of our study was to evaluate the functional and esthetic results of the implant-born dental rehabilitation of the cleft lip and palate patients in our department.

MATERIAL AND METHODS

Our retrospective study concerned patients operated between 1995 and 2010 in our department. All included patients suffered from a cleft alveolus and lip, with or without cleft palate. Dental implants were placed in the bone-grafted alveolus and the end of growth and at distance from the bone graft procedure. Criteria of implant survival and implant-borne rehabilitation success were defined.

RESULTS

A total of 78 implants were placed in 43 patients between 1995 and 2010. Two implants were lost (implant survival rate: 97.4%). Despite this loss, all the patients could be rehabilitated with good functional and esthetic results.

DISCUSSION

Implant-borne rehabilitation is a reliable solution for prosthetic rehabilitation in patients with cleft lip and palate. This solution allows for avoiding removable prosthesis and dental mutilation.

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.

Severe mandibular atrophy treated with a subperiosteal implant and simultaneous graft with rhBMP-2 and mineralized allograft: a case report

A 71-year-old patient was successfully rehabilitated by means of a 3D model-derived, hydroxyapatite-coated titanium subperiosteal mandibular implant. The implant was specifically designed to allow bone augmentation. The deficient bone was simultaneously grafted with mineralized bone allograft and recombinant bone morphogenetic protein -2 (rhBMP-2). The 32-month postoperative cone beam computerized tomography follow-up showed vertical bone augmentation beneath the implant frame.

The use of platelet rich plasma, bone morphogenetic protein-2 and different scaffolds in oral and maxillofacial surgery - literature review in comparison with own clinical experience

Objectives

The purpose of this article was to review and critically assess the use of platelet rich plasma, recombinant human bone morphogenetic protein-2 and different scaffolds (i.e. tricalciumphosphate, polycaprolactone, demineralized bone matrix and anorganic bovine bone mineral) in oral and maxillofacial surgery comparing the relevant literature and own clinical experience.

Material and Methods

A literature review was conducted using MEDLINE, MEDPILOT and COCHRANE DATABASE OF SYSTEMATIC REVIEWS. It concentrated on manuscripts and overviews published in the last five years (2006-2010). The key terms employed were platelet rich plasma, bone morphogenetic proteins and their combinations with the above mentioned scaffolds. The results of clinical studies and animal trials were especially emphasized. The statements from the literature were compared with authors’ own clinical data.

Results

New publications and overviews demonstrate the advantages of platelet rich plasma in bone regeneration. The results from the literature review were discussed and compared with the publications detailing authors' own experiences.

Conclusions

A favourable outcome concerning newly grown bone was achieved combining platelet rich plasma in addition to optimal matrices with or without recombinant human bone morphogenetic protein-2, depending on the clinical case. As a consequence, the paradigm shift from transplantation of autogenous bone to bone tissue engineering appears promising.

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.