Barriers in Accessing Orthodontic Care for Patients with Orofacial Clefts: Insights from a Florida-Based Survey and National Database Analysis

OBJECTIVE

To assess the barriers to obtaining care for patients with orofacial clefts through a survey of Florida-based orthodontists and families and an analysis of the Pediatric Health Information System (PHIS) database.

DESIGN

A cross-sectional study utilizing multiple-choice questionnaires completed by Florida orthodontists and caregivers of patients who attended a Florida-based cleft and craniofacial clinic. Additionally, data from the PHIS database were analyzed to investigate national factors affecting the age of alveolar bone grafting (ABG).

SETTING

Craniofacial team in Florida.

PATIENTS/PARTICIPANTS

The survey included 39 orthodontists (7.1% response rate) and 48 caregivers (41% response rate) The PHIS study included 1182 patients.

MAIN OUTCOME MEASURES

Barrier to orthodontic care and age of ABG.

RESULTS

Orthodontic Survey: Among the surveyed orthodontists, 71% treated cleft/craniofacial patients, 37% accepted Medicaid, and 55% provided pro-bono care. Poor reimbursement was identified as the most common barrier (58%). Caregiver Survey: Most patients were insured by Medicaid (67%), with 55% incurring out-of-pocket expenses. PHIS Database: The average age of ABG was 10.3 years (SD = 3.2). Government funding was associated with a 6.0-month delay in ABG (p = 0.047) and residing in non-Medicaid expanded states was linked to a 6.0-month delay (p = 0.023). Post-Medicaid expansion status was also associated with a delay (p = 0.004).

CONCLUSIONS

Access to oral care is difficult for patients with OFC. Despite both federal and state mandates, many financial and non-financial barriers still exist in accessing orthodontic care and a majority of patients experience significant out-of-pocket expenses despite statutorily mandated insurance coverage.

Racial Disparities in the Timing of Alveolar Bone Grafting

Standard bone grafting between ages 6 and 12 has become the preferred treatment of choice for alveolar clefts. Given the importance of surgical timing in complete cleft palate repairs, it is important to identify any populations at-risk for delayed alveolar bone grafting. The purpose of this study is to identify whether a racial disparity is present nationally in the timing of alveolar bone grafting.

Retrospective analysis Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

Inclusion criteria involved patients who underwent alveolar bone grafting identified by current procedure terminology (CPT) code 42210 between years 2012 and 2019. Patients were stratified by age at time of operation based on the following parameters: early bone grafting (before 6 years of age), standard bone grafting (between 6 and 12 years of age), and late bone grafting (after 12 years of age).

Racial and ethnic differences in the age of patients at the time of alveolar bone grafting.

Overall, 20.28% of the cohort received alveolar bone graft after 12 years of age. African American (29.33%) and Hispanic (24.42%) patients received late alveolar bone grafting more frequently than other racial and ethnic groups (P < .001).

Racial and ethnic disparities are present in the frequency at which patients receive late alveolar bone grafting for complete cleft palates. Given the suboptimal surgical results of late compared to standard alveolar bone grafting it is important to further investigate the driving factors of these disparities.

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.

Secondary Alveolar Bone Grafting in Patients with Unilateral and Bilateral Complete Cleft Lip and Palate: A Single-Institution Outcomes Evaluation Using Three-Dimensional Cone Beam Computed Tomography

BACKGROUND

Secondary alveolar bone grafting of autologous bone from the iliac crest is a widely accepted modality for repair of residual alveolar cleft in patients with mixed dentition with previously repaired complete cleft lip and palate. There remains debate regarding surgical timing and preoperative, perioperative, and postoperative management of these cases.

METHODS

This retrospective study reviewed patient demographic information in addition to preoperative, perioperative, and postoperative course to evaluate how patient and practice factors impact graft outcomes as assessed by three-dimensional cone beam computed tomographic evaluation at the 6-month postoperative visit.

RESULTS

On univariate analysis, age at operation older than 9 years, history of oronasal fistula, history of cleft lip or palate revision, and history of international adoption were all found to significantly increase likelihood of graft failure (p < 0.05). On multivariate analysis, age older than 9 years was found to be the single most significant predictor of graft failure (p < 0.05). There was no significant difference in graft outcomes between patients with unilateral or bilateral cleft lip and palate, and no single variable was found to significantly correlate to increased complication rates. The graft success rate overall of the authors' practice was 86.2 percent, with a complication rate of 7.7 percent.

CONCLUSIONS

Secondary alveolar bone grafting is an integral part of the cleft lip and palate surgical treatment series; this study identified several outcome predictors for both graft failure and adverse events, the most significant of which was age at operation. Although the mixed dentition phase often extends to 12 years of age, it is recommended that bone grafting be performed before 9 years of age to optimize outcomes.

CLINICAL QUESTIONS/LEVEL OF EVIDENCE

Risk, III.

Three-dimensional finite element analysis of the effect of alveolar cleft bone graft on the maxillofacial biomechanical stabilities of unilateral complete cleft lip and palate

BACKGROUND

The objective is to clarify the effect of alveolar cleft bone graft on maxillofacial biomechanical stabilities, the key areas when bone grafting and in which should be supplemented with bone graft once bone resorption occurred in UCCLP (unilateral complete cleft lip and palate).

METHODS

Maxillofacial CAD (computer aided design) models of non-bone graft and full maxilla cleft, full alveolar cleft bone graft, bone graft in other sites of the alveolar cleft were acquired by processing the UCCLP maxillofacial CT data in three-dimensional modeling software. The maxillofacial bone EQV (equivalent) stresses and bone suture EQV strains under occlusal states were obtained in the finite element analysis software.

RESULTS

Under corresponding occlusal states, the EQV stresses of maxilla, pterygoid process of sphenoid bone on the corresponding side and anterior alveolar arch on the non-cleft side were higher than other maxillofacial bones, the EQV strains of nasomaxillary, zygomaticomaxillary and pterygomaxillary suture on the corresponding side were higher than other maxillofacial bone sutures. The mean EQV strains of nasal raphe, the maximum EQV stresses of posterior alveolar arch on the non-cleft side, the mean and maximum EQV strains of nasomaxillary suture on the non-cleft side in full alveolar cleft bone graft model were all significantly lower than those in non-bone graft model. The mean EQV stresses of bilateral anterior alveolar arches, the maximum EQV stresses of maxilla and its alveolar arch on the cleft side in the model with bone graft in lower 1/3 of the alveolar cleft were significantly higher than those in full alveolar cleft bone graft model.

CONCLUSIONS

For UCCLP, bilateral maxillae, pterygoid processes of sphenoid bones and bilateral nasomaxillary, zygomaticomaxillary, pterygomaxillary sutures, anterior alveolar arch on the non-cleft side are the main occlusal load-bearing structures before and after alveolar cleft bone graft. Alveolar cleft bone graft mainly affects biomechanical stabilities of nasal raphe and posterior alveolar arch, nasomaxillary suture on the non-cleft side. The areas near nasal floor and in the middle of the alveolar cleft are the key sites when bone grafting, and should be supplemented with bone graft when the bone resorbed in these areas.

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.

Late alveolar bone grafting in complete unilateral cleft lip and palate (UCLP): Biomechanical considerations for the success of orthodontic finishing

Orthodontic treatment in patients with cleft lip and palate (CLP) is challenging. Alignment of the maxillary segments and orthodontic levelling of the teeth adjacent to the cleft area are important before alveolar bone grafting (ABG), in the permanent dentition. In this clinical report, orthodontic procedures, before and after late ABG, are described as an alternative that can optimise the orthodontic and periodontal results. The gingival margins of the teeth adjacent to the cleft area were levelled. Root divergence was corrected. Interdental papilla and improvement of the periodontal condition were obtained.

Does Early Secondary Alveolar Bone Grafting Influence Need for Additional Maxillary Advancement Procedures in Cleft Lip and Palate?

OBJECTIVE

To determine if secondary alveolar bone grafting (SABG) timing in patients with cleft lip and palate (CLP) influences the future need for additional maxillary advancement procedures, particularly Le Fort I osteotomy with rigid external distraction (RED).

DESIGN

Retrospective cohort study. Groups were separated by SABG timing: early mixed dentition (ages 68 years) or late mixed dentition (ages 9-11 years). The criterion for RED was negative overjet ≥8 mm, and sufficient dental development for RED.

SETTING

Single tertiary care institution.

PATIENTS

Patients with CLP that underwent SABG from 2010 to 2015. Exclusion criteria included syndromic conditions, SABG surgery at age >12 years, current age <12 years, and <2 years follow-up. 104 patients were included.

MAIN OUTCOME MEASURES

The number of RED candidates and treated patients.

RESULTS

There was no statistical difference in the number of RED candidates (P  =  .0718) nor treated patients (P  =  .2716) based on SABG timing; stratification by laterality was also insignificant. Early SABG is associated with higher odds of being a RED candidate (pooled, unilateral, bilateral) and treated patient (pooled and unilateral); however, there were no statistically significant associations between SABG timing and the number of RED candidates and treated patients as determined by logistic regression models.

CONCLUSION

There is no statistically significant association between SABG timing and the odds of being a RED candidate or treated patient. Future prospective studies are recommended to assess the relationship between SABG timing and maxillary growth in patients with CLP.

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.

Three-dimensional tomographic assessment of the upper airway using 2 different imaging software programs: A comparison study

INTRODUCTION

Several imaging software programs with different tools are available for upper airway (UAW) analysis by means of cone beam computed tomography. Because of this wide variability, this study aimed to compare the reproducibility of two of the most used software programs on UAW segmentation, that is, Dolphin Imaging (Dolphin Imaging and Management Solutions, Chatsworth, Calif) and Mimics Research (Materialise, Leuven, Belgium).

METHODS

The sample consisted of 50 scans of adult subjects with Class III malocclusion; pharyngeal volume and minimal cross-sectional area (mCSA) were assessed twice by 2 experienced evaluators using both software programs. Intra- and intersoftware and/or evaluator agreement were calculated using the intraclass correlation coefficient (ICC). Bland-Altman analysis was used to visualize the intersoftware and interevaluator agreement.

RESULTS

Using Mimics Research and Dolphin Imaging, the respective mean values of volume (cm³) were 27.1 ± 8.4 and 24.7 ± 8.1 (P < 0.05) and of mCSA (mm²) were 167.8 ± 95.5 and 176.5 ± 102.3 (P < 0.05). Although differences between software packages were observed on both the analyzed variables, the results showed a high intersoftware agreement, with ICC of 0.87 (volume) and 0.97 (mCSA) and mean bias of 24.6 (volume) and -8.8 (mCSA). A high intrasoftware agreement was also observed, with values varying from 0.83 to 0.99. Excellent intra- and interevaluator agreement was also obtained, with ICC values from 0.93 to 0.99.

CONCLUSIONS

Dolphin Imaging and Mimics Research individually provide highly reproducible results, with clinically acceptable agreement between them for UAW segmentation, providing consistent values for volume and mCSA.

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.

Secondary alveolar bone grafting using autologous versus alloplastic material in the treatment of cleft lip and palate patients: systematic review and meta-analysis

Background

A systematic review assessing autologous versus alloplastic bone for secondary alveolar bone grafting in patients with cleft lip and palate was published in 2011 and included only one randomized controlled trial comparing traditional iliac bone graft to recombinant human bone morphogenetic protein-2 (rh-BMP2).

Objectives

To perform a systematic review with meta-analysis on the use of secondary alveolar bone grafting (autologous bone and rh-BMP2 graft) in order to improve bone volume and height in patients with cleft lip and palate.

Data sources

An electronic search was conducted via PubMed/MEDLINE, Cochrane Central Register of Controlled Trials (CONTROL) via Cochrane Library, EMBASE via Ovid, and LILAC for studies published between January 2008 and September 2018. The systematic review registration number at PROSPERO was 42018085858.

Eligibility criteria

Only RCTs were included. Inclusion criteria were patients with the diagnosis of unilateral cleft lip and palate older than 5 years of age, radiographic evaluation (CT and/or CBCT) of the cleft area, and at least a 6-month follow-up.

Main outcome measures

Bone formation and bone height by radiographic CT evaluation (preoperatively, after 6 months and after 1 year of follow-up) and length of hospital stay were assessed.

Results

Four studies met strict inclusion criteria. Autologous bone graft showed statistically significant higher bone formation after 6-month follow-up (MD − 14.410; 95% CI − 22.392 to − 6.428; p = 0.000). No statistically significant difference was noted after a 1-year follow-up (MD 6.227; 95% CI − 15.967 to 28.422; p = 0.582). No statistically significant difference in bone height was noted after 6-month (MD − 18.737; 95% CI − 43.560 to 6.087; p = 0.139) and 1-year follow-up (MD − 4.401; 95% CI − 30.636 to 21.834; p = 0.742). Patients who underwent rh-BMP2 graft had a statistically significant reduced hospital stay (MD − 1.146; 95% CI − 2.147 to − 0.145; p = 0.025).

Limitations

The main limitation is the high risk of bias among included studies.

Conclusion

Autologous bone and rh-BMP2 graft showed a similar effectiveness in maxillary alveolar reconstruction in patients with unilateral cleft lip and palate assessing bone graft volume and height although rh-BMP2 graft showed a relative shorter length of hospital stay (high uncertainty level).

Electronic supplementary material

The online version of this article (10.1186/s40510-018-0252-y) contains supplementary material, which is available to authorized users.

Eighteen-Year Follow-Up of 160 Consecutive Individuals Born With Unilateral Cleft Lip or Cleft Lip and Alveolus Treated by the Oslo Cleft Lip and Palate Team

OBJECTIVE

Describe patients born with unilateral cleft lip with or without cleft alveolus (CL±A) in relation to cleft severity and laterality, gender, associated anomalies and syndromes, number and type of lip- and nose operations, and time of alveolar bone graft (ABG) treatment in relation to dental status in cleft area.

MATERIALS AND METHODS

Patients included 220 children born with unilateral CL±A, born between 1988 and 1997 referred to the Oslo Cleft Lip and Palate Team. The data were collected retrospectively. All patients were followed up until 18 years of age.

RESULTS

Among all CL±A, 3.6% had recognized syndromes, 6.8% had associated anomalies, and in 89.6% CL±A was the only malformation. CL±A was more common, but not more severe, on the left side. Among the 160 individuals with CL±A without syndromes and associated anomalies, 66.9% had an isolated soft tissue CL, and 33.1% were diagnosed with a CL alveolus (CL+A). Male predominance was observed. Children with CL+A had more severe soft tissue clefts of the lip and underwent more lip and nose surgeries than children born with CL. The time of ABG was found to be at a younger age when the patient had a lateral incisor in the cleft area than when this tooth was missing.

CONCLUSION

Findings provide a reference for morphologic variations in CL±A, and insight into the surgical burden of care until the age of 18 years.