Outcome of secondary alveolar bone grafting before and after eruption of the canine in Jordanian patients with cleft lip and palate

Timing of Alveolar Bone Graft and Barriers to Care

OBJECTIVE

The current standard timing for alveolar bone grafting (ABG) occurs during mixed dentition, typically between the ages of six and twelve. A delay in receiving this operation is associated with an increase in graft loss and an overall thinner maxilla. This study aims to determine whether socioeconomic barriers are associated with a delay in timely ABG.

DESIGN

A retrospective analysis of patients who received ABG at our institution since 2012. Patient demographics, cleft classifications, operative details, and surgical dates were examined. A logistic regression model was created using socioeconomic variables to predict patients receiving delayed ABG. Significant variables were then included in a backwards selection logistic regression, followed by a final analysis of maximum likelihood estimates.

SETTING

Single-institution, primary cleft care center.

PATIENTS

202 patients with cleft palates who underwent ABG.

INTERVENTIONS

ABG.

MAIN OUTCOME MEASURES

Timing in which patients received ABG: standard (6-12 years) and delayed (>12 years).

RESULTS

Female sex was a protective factor in the timing of ABG in our initial univariate analysis (OR = 0.44; p  =  .015). Socioeconomic factors resulting in delayed presentation for ABG include median income (OR = 1.0; p  =  .018) and public insurance status (OR = 3.75; p < .001). Median income, sex, and driving distance to the cleft clinic were not significant following backward elimination, however, private insurance status remained significant (OR = 3.71; p  =  .0001).

CONCLUSION

Patients with public insurance are approximately 3.75 times more likely to receive ABG during permanent dentition. Multidisciplinary teams should work closely with patients on public insurance to ensure timely delivery of ABG.Level of Evidence III, Retrospective.

Effect of Platelet-rich Plasma on the Clinical Success of Alveolar Grafts in Patients With Cleft Lip and Palate: A Systematic Review and Meta-Analysis

OBJECTIVES

This study assessed the effect of platelet-rich plasma (PRP) on the clinical success of alveolar grafts in patients with cleft lip and palate.

MATERIALS AND METHODS

In this meta-analysis, a search of the literature was conducted in Medline, Scopus, ISI Web of Science, and Cochrane Central Register of Controlled Trials for randomized clinical trials using PRP or platelet-rich fibrin (PRF) along with autogenous bone for alveolar ridge grafts in patients with cleft lip and palate. The methodological quality of the studies was analyzed using Cochrane's risk of the bias assessment tool. The extracted data underwent meta-analysis using the random-effects model.

RESULTS

Of a total of 2256 articles retrieved, 12 met the eligibility criteria and were enrolled; out of which 6 did not undergo meta-analysis due to heterogeneous data. The percentage of defects filled by bone graft was 0.648% (95% confidence interval: -0.15 to 1.45), which was not statistically significant ( P =0.115). Subgroup analysis showed no significant difference based on the use of PRF or PRP ( P =0.28), type of cleft (unilateral/bilateral; P =0.56), or type of radiographic modality (3D/2D; P =0.190). Meta-regression analysis showed that the duration of follow-up and the difference in the mean age of patients did not have a significant effect on the results (R=0, I2: high).

CONCLUSION

The application of PRP/PRF in combination with autogenous bone graft did not have a significant effect on the percentage of alveolar cleft filled by a bone graft. Future clinical studies are required to further elucidate the effect of PRP in the regeneration of alveolar clefts.

Predictive factors for secondary alveolar bone graft failure in patients with cleft alveolus

OBJECTIVE

This single-centre retrospective cohort study aimed to evaluate secondary alveolar bone grafting (SABG) and identify the factors associated with failure.

METHODS

Individuals born with alveolar cleft with or without cleft palate who had SABG consecutively between 2004-2006 and 2011-2013 were enrolled in this study. After the exclusion of 20 cases due to poor quality radiographs, 115 patients (50 girls and 65 boys) who had undergone 131 SABG procedures were included. According to a modification of the Bergland Scale (mBS), the alveolar bone level was assessed using occlusal films obtained 3 months after SABG. Data on factors plausible for SABG failure were collected from patient records, photographs, cast models, and presurgical occlusal radiographs. The Mantel Haenszel Chi-Square test was used to test the possible impact of these factors on the mBS scores.

RESULTS

A total failure (mBS score of 4) was observed in 9% of the cases. The alveolar bone level correlated with cleft laterality (P = 0.039), alveolar cleft extension (P = 0.033), age at SABG (P = 0.007), root developmental stage (P = 0.021), and oral hygiene (P = 0.007).

CONCLUSION

Secondary alveolar bone grafting failure was correlated with a bilateral alveolar cleft, absence of an initial partial alveolar bridge, higher age, increased root developmental stage, and poor oral hygiene. Efforts to achieve optimal oral hygiene are recommended to improve outcomes, particularly when SABG is performed in individuals with a bilateral cleft, increased alveolar cleft extension, or at higher ages.

Alveolar Bone Graft Timing in Patients With Cleft Lip & Palate

ABSTRACT

Cleft lip with or without cleft palate (CLP) is the most common craniofacial condition. Alveolar clefts are present in approximately 75% of patients with a cleft lip or CLP and often do not have sufficient support of surrounding teeth. Alveolar bone graft is commonly performed to reconstruct alveolar ridge in patient with osseous defects. Objective of this review is to critically analyze the literature to provide recommendations on appropriate timing for orthodontic preparation and surgical correction of alveolar clefts in the setting of unilateral or bilateral CLP. Search of PubMed database, MEDLINE, and EMBASE was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 15 studies were included. Majority of studies used chronological age to classify patients versus dental age. Most studies reported orthodontic treatment concomitant with surgery (12/15; 80.0%), and used orthodontics before alveolar bone grafting (8/12; 66.7%). No consensus on the best method to evaluate the success of alveolar bone grafting. Alveolar bone grafting with pre- and post-operative orthodontics is currently the standard of care for treatment of alveolar defects in patients with CLP. Authors recommend grafting during early mixed dentition phase, just before the eruption of the permanent central incisors, typically between 6 and 8 years old. Preoperative orthodontics for appropriate incisor alignment around cleft, and may be resumed 6 months postoperative.

Clinical Practice Guidelines on the Treatment of Patients with Cleft Lip, Alveolus, and Palate: An Executive Summary

Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.

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.

Outcome after secondary alveolar bone grafting among patients with cleft lip and palate at 16 years of age: a retrospective study

OBJECTIVE

To evaluate the outcome of secondary alveolar bone grafting (SABG) in patients with cleft lip and palate at 16 years of age and to identify predictors associated with surgical failure.

STUDY DESIGN

This retrospective follow-up included 91 patients with 100 cleft palates treated with SABG at a mean age of 9.2 years. The possible predictors for surgical failure analyzed were sex, dental development stadium, type of cleft, side, tooth erupting into the graft, cortical boundary, presence of a lateral incisor, extraction, preoperative expansion, oral hygiene, retention device, and age. The outcome variable for surgical success was Bergland score I and II. Surgical outcome was analyzed at 16 years of age based on intraoral radiographs, according to the Bergland index. Statistical analyses included estimation of odds ratios for predictor variables.

RESULTS

The post-SABG success rate was 91% (Bergland score I and II) with a mean follow-up of 7.2 years. Surgical failure was significantly associated with poor oral hygiene.

CONCLUSIONS

This study revealed a high success rate (91%) at a mean of 7.2 years post-SABG. Poor oral hygiene significantly increased the risk of surgical failure. This suggests that increased perioperative measures to maintain good oral health could reduce surgical failure.

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.

Regeneration in Experimental Alveolar Bone Defect Using Human Umbilical Cord Mesenchymal Stem Cells

Cleft lip and palate is a congenital disorder including cleft lip, and/or cleft palate, and/or alveolar cleft, with high incidence.The alveolar cleft causes morphological and functional abnormalities. To obtain bone bridge formation and continuous structure between alveolar clefts, surgical interventions are performed from infancy to childhood. However, desirable bone bridge formation is not obtained in many cases. Regenerative medicine using mesenchymal stem cells (MSCs) is expected to be a useful strategy to obtain sufficient bone bridge formation between alveolar clefts. In this study, we examined the effect of human umbilical cord-derived MSCs by transplantation into a rat experimental alveolar cleft model. Human umbilical cords were digested enzymatically and the isolated cells were collected (UC-EZ cells). Next, CD146-positive cells were enriched from UC-EZ cells by magnetic-activated cell sorting (UC-MACS cells). UC-EZ and UC-MACS cells showed MSC gene/protein expression, in vitro. Both cells had multipotency and could differentiate to osteogenic, chondrogenic, and adipogenic lineages under the differentiation-inducing media. However, UC-EZ cells lacked Sox2 expression and showed the lower ratio of MSCs than UC-MACS cells. Thus, UC-MACS cells were transplanted with hydroxyapatite and collagen (HA + Col) into alveolar cleft model to evaluate bone formation in vivo. The results of micro computed tomography and histological staining showed that UC-MACS cells with HA + Col induced more abundant bone formation between the experimental alveolar clefts than HA + Col implantation only. Cells immunopositive for osteopontin were accumulated along the bone surface and some of them were embedded in the bone. Cells immunopositive for human-specific mitochondria were aligned along the newly formed bone surface and in the new bone, suggesting that UC-MACS cells contributed to the bone bridge formation between alveolar clefts. These findings indicate that human umbilical cords are reliable bioresource and UC-MACS cells are useful for the alveolar cleft regeneration.

Autogenous Iliac Crest Versus rhBMP-2 for Alveolar Cleft Grafting: A 14-Year Single-Institution Experience

PURPOSE

This study sought to compare radiographic outcomes and resource utilization between recombinant human bone morphogenetic protein-2 (rhBMP-2) and anterior iliac crest bone graft (AICBG) when used for secondary alveolar grafting.

MATERIALS AND METHODS

This is a 14-year retrospective study of patients with alveolar clefts treated at the Morgan Stanley Children's Hospital of New York-Presbyterian/Columbia University Irving Medical Center between January 2006 and January 2020. Patients who had alveolar grafting with either rhBMP-2 or AICBG were included in this study. The primary study predictor was the graft material. The study outcomes were bone height, operating room time, and the number of scrubbed personnel (surgeon and assistants). Graft survival was measured at a minimum of 6 months postoperatively. Bone height was scored according to the Bergland scale, and radiographic success was defined as Bergland types 1 or 2.

RESULTS

The study sample included a total of 115 patients with 130 alveolar clefts. Overall, 13.0% of patients had bilateral repairs, and 17.4% were retreatments. The cumulative success rate was 89.5%. There were no differences in success between materials (rhBMP: 90.3%; AICBG: 89.1%; P = .85). Patients presenting for retreatment were more likely to receive rhBMP-2 than AICBG (48.6 vs 3.8%, P < .01). After controlling for other significant confounders, the rhBMP-2 group required less personnel (P < .01) and operating room time (P < .01). Only 1 patient in the rhBMP-2 group was admitted, whereas all AICBG patients were admitted a minimum of 1 night.

CONCLUSIONS

Compared with AICBG, rhBMP-2 produced a similar height of bone but required less hospital resources. The decision to use harvested ilium or rhBMP-2 is not limited by outcome data at this time. More studies will need to be performed to identify the particular advantages of each graft material. The choice of material is currently both surgeon specific and patient specific and requires thorough informed consent.

Comparison of dental outcomes in patients with nonsyndromic complete unilateral cleft lip and palate who receive secondary alveolar bone grafting before or after emergence of the permanent maxillary canine

INTRODUCTION

For patients with complete unilateral cleft lip and palate (CUCLP), secondary alveolar bone grafting (SABG) can be performed before or after the emergence of the cleft side permanent canine (pre-CE and post-CE, respectively). The controversy regarding dental outcomes related to the timing of SABG remains unsettled. The objective of this study was to evaluate dental survival and specific dental outcomes of cleft-adjacent teeth in children with CUCLP who received either pre-CE or post-CE SABG.

METHODS

The permanent maxillary canines and the central and lateral incisors of 21 pre-CE and 23 post-CE SABG subjects with nonsyndromic CUCLP and all cleft-related surgeries performed by the same surgeon were analyzed retrospectively. Intraoral radiographs and clinical chart notes were collected at age 7 years, at the time of the SABG, and approximately 4 years after the grafting. Dental survival, spontaneous canine eruption, planned prosthetic replacement, root development, and root resorption were analyzed.

RESULTS

Dental outcomes on the noncleft side were better than those on the cleft side. On the cleft side, dental survival of the cleft-adjacent teeth was not significantly different between the pre-CE and post-CE SABG groups (P >0.05). Most teeth completed root development after grafting, and the cleft side canine root development in the pre-CE SABG group appeared to accelerate after SABG. Trends showed that the pre-CE SABG group suffered less root resorption (16.28%; post-CE: 22.73%; P >0.05) and received fewer planned prosthetic replacements (14.29%; post-CE: 26.01%; P >0.05) but required a greater number of canine exposures (33.33%; post-CE: 4.55%; P = 0.02).

CONCLUSIONS

Pre-CE SABG showed better dental outcomes in patients with CUCLP, with fewer adverse dental outcomes than post-CE SABG.

Comparison of early and conventional autogenous secondary alveolar bone graft in children with cleft lip and palate: A systematic review

PURPOSE

The literature is scarce on studies comparing secondary alveolar bone graft (SABG) performed early at approximately 5-6 years and at the conventional time at 9-11 years. This systematic literature review(SLR) aimed to compare clinical outcomes after two different timings of SABG in children with unilateral and bilateral cleft lip and palate.

METHODS

The inclusion criteria were autogenous iliac grafts and the following study designs: case control, cohort, clinical controlled trial (CCT), randomized CCT (RCCT), and previous SLRs. Ovid MEDLINE, Ovid EMBASE, Web of Science, Scopus, Cochrane, ProQuest and Google Scholar were the primary databases. Two calibrated examiners worked independently to select the articles. The MINORS evaluation method for surgical non-RCTs was used to assess for quality.

RESULTS

1,111 articles were retrieved and 19 qualified. Different clinical and radiographic outcomes such as bone level, periodontal status, canine eruption and cleft-side tooth survival were evaluated by different assessment methods such as CBCT volume, computed tomography, periodontal evaluation, panoramic, intraoral radiographs, and Bergland scale. No RCCT or meta-analysis was found. None of the studies received the ideal score, which is 16 for non-comparison studies and 24 for comparison studies.

CONCLUSION

Methodological variation, lack of standardization for initial cleft dimension and low-quality level rendered a fair comparison unfeasible. Although further studies are necessary, it can be assumed that early SABG also can be an acceptable option, but this was based on a single study with a reasonable level of evidence.

Synchronous correction in secondary cleft deformities: a prospective cohort study

BACKGROUND

Patients with cleft lip and palate deformities undergo multiple surgical procedures from infancy till adolescence. We hypothesized that combining these surgical procedures might offer a better quality of life without compromising on surgical outcomes.

METHODS

A prospective cohort study was conducted at our center including all adult patients who reported to us for the correction of secondary cleft deformities. All patients with secondary deformities associated with cleft lip palate and alveolus were enrolled in the study. Patients with medical issues who are not fit for general anesthesia, Bilateral Cleft deformities, and patients with gross skeletal deformity warranting surgical correction by Le fort I distraction were excluded from the study. All the patients who were included in the study underwent simultaneous lip revision, rhinoplasty and cleft alveolar bone grafting. The outcome lip nose profile was assessed using standardized patient photographs with Ascher Mcdade Scale and Aesthetic outcome index by 2 blinded maxillofacial surgeons and the bone grafting was assessed using Berglands grading system.

RESULTS

Twenty-eight patients were enrolled in the study, 10 patients were excluded based on the exclusion criteria. Thus 18 patients planned for synchronous correction of unilateral secondary cleft deformities were included in the study The Ascher Mcdade Score improved from 15 (13-16), to 4 (4-5) in the post op. All the patients were totally satisfied with the surgical outcome. The aesthetic index showed excellent outcomes in all the lip-nose procedures, except for one case which showed a good outcome. The Bergland Scale showed normal bone height in all cases of alveolar bone grafting, except for one case, which showed less than 3/4^th fill of bone. No complications were associated with any of the procedures.

CONCLUSIONS

Simultaneous correction of multiple secondary cleft lip deformities should be considered when feasible, to improve the psychological benefit and reduce financial burden on these patients. However, careful planning and execution of the techniques is essential to avoid complications associated with vascular compromise.

Incidence of complications in secondary alveolar bone grafting of bilateral clefts with premaxillary osteotomy: a retrospective cohort study

OBJECTIVE

To evaluate factors affecting incidence of complications after secondary alveolar bone grafting with premaxillary osteotomy (SABG + PO) in children with complete bilateral cleft of lip and palate (BCLP).

MATERIALS AND METHODS

Data were collected from children with BCLP treated with SABG + PO from 2004 to 2014 at our institute. Preoperative parameters included age, donor site, race, gingival health, bone quality around cleft-related teeth, premaxilla position, graft timing, presence of canines in the cleft, and presence of deciduous teeth around the cleft area. Logistic regression and the chi-squared test were used to assess correlations and the incidence of complications.

RESULTS

In the 64 patients, a significant correlation was found between complication rate and timing of bone grafting with respect to early versus late SABG + PO (p = 0.041), age > 12 years (p = 0.011; odds ratio (OR) 5.9; 95% confidence interval (CI) 1.49-23.93), malposition of the premaxilla (p = 0.042; OR 3.3; 95% CI 1.04-10.13), and preoperative bone quality around cleft-related teeth (p = 0.005; OR 5.3; 95% CI 1.6-17.2).

CONCLUSIONS

The timing of SABG + PO is essential, as early SABG + PO is associated with fewer complications. A malpositioned premaxilla and poor bone quality around cleft-related teeth are associated with more complications. Therefore, preoperative orthodontic repositioning of the malpositioned premaxilla before SABG + PO should be considered.

CLINICAL RELEVANCE

Analysis of treatment protocols and complications for BCLP patients underscores that proper timing of SABG + PO and correct premaxilla repositioning help reduce complications.

Secondary Alveolar Bone Grafting (CLEFTSiS) 2007–2010

Objective

To determine whether alveolar bone graft outcomes for unilateral and bilateral cleft lip and palate patients have continued to improve since the reorganization of cleft services in Scotland in 2000.

Design

Retrospective analysis of postoperative anterior occlusal radiographs. Patients and Participants: Eighty-one of 106 patients who were eligible for alveolar bone grafting between 2007 and 2010 had suitable postoperative radiographs available.

Interventions

Twenty-seven percent of the patients (n = 22) had presurgical orthodontic intervention. All patients underwent alveolar bone grafting with bone harvested from the iliac crest.

Main Outcome Measures

The Kindelan bone-fill index was used to evaluate success. Weighted kappa statistics were used to assess intra- and interobserver reproducibility. A comparison was made with results from 2000 to 2004 to assess any improvement. Chi-square tests (or Fisher exact test) were used to determine whether outcomes differed depending on the laterality of the cleft, use of presurgical expansion, or age at bone grafting.

Result

Interobserver scoring agreement was good (weighted kappa = .383). Intraobserver reproducibility was greater (weighted kappas of .835 and .620). Success was achieved in 99% of bone grafts, compared with 76% in the period from 2000 to 2004 (P < .001). There was no statistically significant relationship between the laterality of the cleft (P = 1.000), use of presurgical expansion (P = 1.000), or age at time of bone grafting and outcome (P = .259).

Conclusion

Scottish secondary alveolar bone graft outcomes improved during 2007 to 2010 in comparison to the 2000 to 2004 results.

Risk factor analysis of bone resorption following secondary alveolar bone grafting using three-dimensional computed tomography

BACKGROUND/AIM

The purpose of this study is to analyze the risk factors for bone resorption following secondary bone grafting in the alveolar cleft, using three-dimensional (3D) computed tomography (CT) based on surgical simulation software (SimPlant OMS, Materialise Dental, Leuven, Belgium).

METHODS

We reviewed the secondary alveolar bone grafts performed by a single surgeon between January 2005 and January 2014. A total of 40 patients with unilateral alveolar cleft were included in this study. The grafted alveolar bone was measured using surgical simulation software. In order to validate the measurement, each data set was measured by three different analysts and the inter- and intraobserver variabilities were calculated. A total of eight risk factors for grafted bone survival, including patient age, sex, body mass index (BMI), palatal fistula, amount of grafted bone, dental appliance, canine or incisor eruption, and preoperative upper respiratory tract infection, were evaluated using the linear mixed model and Mann-Whitney test.

RESULTS

The average alveolar defect size was 4.98 cc and the average graft survival was 67.5%. The inter- and intraobserver variabilities of simulation software were 0.758 and 0.915, respectively. Among the risk factors, only dental appliance (p = 0.02) and canine eruption (p = 0.041) were significantly correlated with graft survival. Other risk factors, including the amount of grafted bone, did not show a significant relationship with graft survival.

CONCLUSION

Measurement of an alveolar bone defect using a simulation program based on 3D CT is reliable and reproducible. Secondary bone grafting survival was significantly correlated with canine eruption and dental appliance in the alveolar cleft.

Ideal treatment protocol for cleft lip and palate patient from mixed to permanent dentition

A girl with an Angle Class III malocclusion, anterior and posterior crossbites, a concave profile, and cleft lip and palate sought orthodontic treatment. She was treated with a multidisciplinary therapeutic protocol including orthodontic and surgical procedures. The proposed objectives of occlusion, normal function, and balanced profile were achieved, and these results remained stable 4 years after the treatment.

Secondary bone grafting for alveolar cleft in children with cleft lip or cleft lip and palate

BACKGROUND

Secondary alveolar bone grafting has been widely used to reconstruct alveolar cleft. However, there is still some controversy.

OBJECTIVES

To compare the effectiveness and safety of different secondary bone grafting methods.

SEARCH STRATEGY

The final electronic and handsearches were carried out on 11 February 2011, and included the Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Chinese Biomedical Literature Database and WHO International Clinical Trials Registry Platform. All the Chinese professional journals in the oral and dental field were handsearched and conference proceedings consulted. There was no language or time restriction.

SELECTION CRITERIA

Only randomized clinical trials were selected. Patients with the diagnosis of cleft lip and alveolar process only, unilateral cleft lip and palate and bilateral cleft lip and palate involving the alveolar process and greater than 5 years of age were included.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed the quality of included studies independently. Disagreement between the two review authors was resolved by discussion in the review team. The first authors of the included studies were contacted for additional information, if necessary.

MAIN RESULTS

Two of 582 potential studies met the inclusion criteria and were included. One trial compared alveolar bone grafting using artificial materials (InFuse bone graft substitute impregnated with BMP-2) with a traditional iliac graft. The other trial investigated the application of fibrin glue to the bone graft. Both trials were small with 21 and 27 patients and were assessed as being at high risk of bias. Any apparent differences between the interventions for outcomes in either study must therefore be treated with great caution and are not highlighted here.

AUTHORS' CONCLUSIONS

Due to the high level of risk of bias in the two included trials there is insufficient evidence to conclude that one intervention is superior to another.

Reconstruction of the alveolar cleft: can growth factor-aided tissue engineering replace autologous bone grafting? A literature review and systematic review of results obtained with bone morphogenetic protein-2

The alveolar cleft in patients with clefts of lip, alveolus and palate (CLAP) is usually reconstructed with an autologous bone graft. Harvesting of autologous bone grafts is associated with more or less donor site morbidity. Donor site morbidity could be eliminated if bone is fabricated by growth factor-aided tissue engineering. The objective of this review was to provide an oversight on the current state of the art in growth factor-aided tissue engineering with regard to reconstruction of the alveolar cleft in CLAP. Medline, Embase and Central databases were searched for articles on bone morphogenetic protein 2 (BMP-2), bone morphogenetic protein 7, transforming growth factor beta, platelet-derived growth factor, insulin-like growth factor, fibroblast growth factor, vascular endothelial growth factor and platelet-rich plasma for the reconstruction of the alveolar cleft in CLAP. Two-hundred ninety-one unique search results were found. Three articles met our selection criteria. These three selected articles compared BMP-2-aided bone tissue engineering with iliac crest bone grafting by clinical and radiographic examinations. Bone quantity appeared comparable between the two methods in patients treated during the stage of mixed dentition, whereas bone quantity appeared superior in the BMP-2 group in skeletally mature patients. Favourable results with BMP-2-aided bone tissue engineering have been reported for the reconstruction of the alveolar cleft in CLAP. More studies are necessary to assess the quality of bone. Advantages are shortening of the operation time, absence of donor site morbidity, shorter hospital stay and reduction of overall cost.

Secondary Alveolar Bone Grafting (CLEFTSiS) 2000–2004

Objective

To determine whether alveolar bone graft outcomes improved with reorganization of Scottish cleft services following the Clinical Services Advisory Group United Kingdom finding of 58% success and to determine the accuracy of results from CLEFTSiS (national managed clinical network for Scottish cleft services) annual audits.

Design

Retrospective random analysis of electronic radiographs by two observers.

Setting

Surgical-orthodontic care provided through National Health Service.

Patients, Participants

Sixty-three of 261 patients eligible for alveolar bone grafting by cleft type did not undergo surgery. Nine surgeons operated on 198 patients (2 regrafts). Radiographs were available for 115 subjects (one was excluded).

Interventions

A standard protocol involved presurgical maxillary expansion (where necessary) and bone harvesting from the iliac crest.

Main Outcome Measure(s)

The Kindelan Bone-Fill Index evaluated radiographic success with weighted kappa statistics for intraobserver and interobserver reproducibility. Two-sample t-tests were used to determine whether outcomes for bilateral and unilateral cleft lip and palate patients differed and to examine the effects of operator volume, presurgical expansion, and age at the time of grafting.

Results

Intraobserver (0.93 to 0.97) and interobserver (0.83 to 0.85) reproducibility were almost perfect. Grafts were successful in 76% of patients, while 23% were partial failures and 1% of cases were total failures. Patients who underwent presurgical expansion (n  =  64) had statistically significantly better results ( p  =  .046). However, there was no statistically significant effect for unilateral versus bilateral patients ( p  =  .77), patients treated by the highest volume operator ( p  =  .78), and patients under 11 years of age ( p  =  .29).

Conclusions

CLEFTSiS alveolar bone graft results between 2000 and 2004 were improved on the Clinical Services Advisory Group study and annual CLEFTSiS audits. Patients who underwent maxillary expansion prior to surgery were more successful.