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Roohani I, Choi DG, Stanton EW, Trotter C, Turk M, Naidu P, Urata MM, Magee WP, Hammoudeh JA. Inpatient versus Outpatient Alveolar Bone Grafting: A Nationwide Cost Analysis. Cleft Palate Craniofac J 2024:10556656241256916. [PMID: 38840317 DOI: 10.1177/10556656241256916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
OBJECTIVE To compare postoperative outcomes and costs between inpatient and outpatient ABG in the United States. DESIGN Retrospective cohort. SETTING Multi-institutional/national. PATIENTS AND PARTICIPANTS Patients who underwent ABG (n = 6649) were identified in the National Surgical Quality Improvement Program Pediatric database from 2012-2021. Inpatient and outpatient cohorts were matched using coarsened exact matching. MAIN OUTCOMES MEASURE(S) Thirty-day readmission, reoperation, and complications. A modified Markov model was developed to estimate the cost difference between cohorts. One-way and probabilistic sensitivity analyses were performed. RESULTS After matching, 3718 patients were included, of which 1859 patients were in each hospital-setting cohort. The inpatient cohort had significantly higher rates of reoperations (0.6% vs. 0.2%; p = 0.032) and surgical site infections (0.8% vs. 0.2%; p = 0.018). The total cost of outpatient ABG was estimated to be $10,824 vs. $20,955 for inpatient ABG, resulting in $10,131 cost savings per patient. Probabilistic sensitivity analysis revealed that all 10,000 simulations resulted in consistent cost savings for the outpatient cohort that ranged from $8000 to $24,000. CONCLUSIONS Outpatient ABG has become increasingly more popular over the past ten years, with a majority of cases being performed in the ambulatory setting. If deemed safe for the individual patient, outpatient ABG may confer a lower risk of nosocomial complications and offer significant cost savings to the healthcare economy.
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Affiliation(s)
- Idean Roohani
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Dylan G Choi
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Eloise W Stanton
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Collean Trotter
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Marvee Turk
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Priyanka Naidu
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Mark M Urata
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
- Division of Oral and Maxillofacial Surgery, Keck School of Medicine, Los Angeles, CA, USA
- Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
| | - William P Magee
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Jeffrey A Hammoudeh
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
- Division of Oral and Maxillofacial Surgery, Keck School of Medicine, Los Angeles, CA, USA
- Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
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Bushong EE, Patmon D, Pfershy H, Huffman C, Carlson A, Girotto J. Timing of Alveolar Bone Graft and Barriers to Care. Cleft Palate Craniofac J 2024:10556656241242695. [PMID: 38576319 DOI: 10.1177/10556656241242695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
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.
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Affiliation(s)
| | - Darin Patmon
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Corewell Health, Grand Rapids, MI, USA
- Corewell Health/Michigan State University Plastic Surgery Residency, Grand Rapids, MI, USA
| | - Hanna Pfershy
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | | | - Anna Carlson
- Corewell Health/Michigan State University Plastic Surgery Residency, Grand Rapids, MI, USA
- Pediatric Plastic and Craniofacial Surgery, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - John Girotto
- Corewell Health/Michigan State University Plastic Surgery Residency, Grand Rapids, MI, USA
- Pediatric Plastic and Craniofacial Surgery, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
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Brudnicki A, Petrova T, Dubovska I, Kuijpers-Jagtman AM, Ren Y, Fudalej PS. Alveolar Bone Grafting in Unilateral Cleft Lip and Palate: Impact of Timing on Palatal Shape. J Clin Med 2023; 12:7519. [PMID: 38137587 PMCID: PMC10743654 DOI: 10.3390/jcm12247519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/24/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Alveolar bone grafting (ABG) is a critical surgical intervention in patients with a cleft of the alveolus, aimed at reconstructing the alveolar ridge to facilitate proper eruption, periodontal support, and alignment of adjacent permanent teeth. The optimal timing for ABG remains debated, with late secondary ABG between the ages of 9 and 11 being widely adopted. This study compared the palatal shapes of 28 children at a mean age of 9.5 years (SD = 0.7) who underwent early secondary ABG at a mean age of 2.1 years (SD = 0.6) or 33 children at a mean age of 10.8 years (SD = 1.5) who underwent late secondary ABG at a mean age of 8.6 years (SD = 1.3) to 60 non-cleft controls at a mean age of 8.6 years (SD = 1.2). The palatal shapes were captured with 239 landmarks digitized on the palate on a digital model. Utilizing geometric morphometric methods, i.e., generalized Procrustes superimpositions, principal component analysis, and permutation tests, we assessed the impact of ABG timing on palatal morphology. The first five principal components (PCs) explained 64.1% of the total shape variability: PC1 = 26.1%; PC2 = 12%; PC3 = 11.9%; PC4 = 7.8%; and PC5 = 6.4%. The Procrustes distance between both cleft groups and the control group was more than twice as large as the Procrustes distance between the early ABG and late ABG groups. Nonetheless, all intergroup differences were statistically significant. Our findings suggest that early ABG has a limited negative effect on palatal shape, providing comparable outcomes to late ABG. The study highlights the potential suitability of early ABG, challenging conventional practices and encouraging further exploration into its long-term effects on maxillary growth.
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Affiliation(s)
- Andrzej Brudnicki
- Department of Pediatric Surgery, Institute of Mother and Child, 01-211 Warsaw, Poland;
| | - Tereza Petrova
- Department of Orthodontics and Cleft Anomalies, 3rd Medical Faculty, Faculty Hospital Royal Vineard, Dental Clinic, Charles University, 11636 Prague, Czech Republic;
| | - Ivana Dubovska
- Institute of Dentistry and Oral Sciences, Faculty of Medicine and Dentistry, Palacký University Olomouc, 77900 Olomouc, Czech Republic (P.S.F.)
| | - Anne Marie Kuijpers-Jagtman
- Department of Orthodontics, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
- Department of Orthodontics and Dentofacial Orthopedics, School of Dental Medicine, Medical Faculty, University of Bern, 3010 Bern, Switzerland
- Faculty of Dentistry, Universitas Indonesia, Campus Salemba, Jakarta 10430, Indonesia
| | - Yijin Ren
- Department of Orthodontics, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Piotr S. Fudalej
- Institute of Dentistry and Oral Sciences, Faculty of Medicine and Dentistry, Palacký University Olomouc, 77900 Olomouc, Czech Republic (P.S.F.)
- Department of Orthodontics and Dentofacial Orthopedics, School of Dental Medicine, Medical Faculty, University of Bern, 3010 Bern, Switzerland
- Department of Orthodontics, Jagiellonian University in Cracow, 31-007 Krakow, Poland
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Parham MJ, Simpson AE, Moreno TA, Maricevich RS. Updates in Cleft Care. Semin Plast Surg 2023; 37:240-252. [PMID: 38098682 PMCID: PMC10718659 DOI: 10.1055/s-0043-1776733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.
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Affiliation(s)
- Matthew J. Parham
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Arren E. Simpson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Tanir A. Moreno
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Renata S. Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
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5
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Cleft and Craniofacial Surgery. J Oral Maxillofac Surg 2023; 81:E120-E146. [PMID: 37833020 DOI: 10.1016/j.joms.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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Qamar F, Cray JJ, Halsey J, Rottgers SA. A Survey of Bone Grafting Practice Patterns in North American Cleft Surgeons. Cleft Palate Craniofac J 2023; 60:1366-1375. [PMID: 36314735 DOI: 10.1177/10556656221104937] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
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.
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Affiliation(s)
- Fatima Qamar
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital; St. Petersburg, FL, USA
| | - James J Cray
- Department of Biomedical Education and Anatomy, The Ohio State University College of Medicine, and Division of Biosciences, The Ohio State University College of Dentistry, Columbus, OH, USA
| | - Jordan Halsey
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital; St. Petersburg, FL, USA
- Department of Plastic and Reconstructive Surgery, University of South Florida Morsani College of Medicine; Tampa, FL, USA
| | - S Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital; St. Petersburg, FL, USA
- Department of Plastic and Reconstructive Surgery, University of South Florida Morsani College of Medicine; Tampa, FL, USA
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7
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Long RE, Hathaway RR. Practice-based Evidence from Comparative Effectiveness Research to Inform Evidence-based Practice. Cleft Palate Craniofac J 2023:10556656231198661. [PMID: 37649309 DOI: 10.1177/10556656231198661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Affiliation(s)
- Ross E Long
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
| | - Ronald R Hathaway
- Orthodontics and Pediatric Dentistry, University of Michigan, Ann Arbor, MI, USA
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8
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Gillgrass T. The orthodontic management of patients with cleft lip and palate: from birth to the late mixed dentition. Br Dent J 2023; 234:873-880. [PMID: 37349434 DOI: 10.1038/s41415-023-5955-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 06/24/2023]
Abstract
This is the first of two papers outlining the orthodontic management of patients with cleft lip and palate. This paper will review orthodontic input into children with cleft lip and palate from birth to the late mixed dentition before definitive orthodontics. It will emphasise the importance of timing in alveolar bone grafting, the role of the general dental practitioner and the impact of timing on definitive orthodontic outcome.
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Affiliation(s)
- Toby Gillgrass
- Cleft Surgical Service for Scotland & Glasgow Dental Hospital and School, Glasgow, United Kingdom.
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9
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Kim J, Jeong W. Secondary bone grafting for alveolar clefts: surgical timing, graft materials, and evaluation methods. Arch Craniofac Surg 2022; 23:53-58. [PMID: 35526839 PMCID: PMC9081425 DOI: 10.7181/acfs.2022.00115] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/19/2022] [Indexed: 11/11/2022] Open
Abstract
Alveolar cleft belongs to the spectrum of cleft lip and/or palate, affecting 75% of cleft lip/palate patients. The goals of alveolar cleft treatment are stabilizing the maxillary arch, separating the nasal and oral cavities, and providing bony support for both erupting teeth and the nasal base via the piriform aperture. Secondary alveolar bone grafting is a well-established treatment option for alveolar cleft. Secondary alveolar bone grafting is performed during the period of mixed dentition using autologous bone from various donor sites. There are several issues relevant to maximizing the success of secondary alveolar bone grafting, including the surgical timing, graft material, and surgical technique. In this study, we reviewed issues related to surgical timing, graft materials, and evaluation methods in secondary alveolar bone grafting.Abbreviations: ABG, alveolar bone grafting; CBCT, cone-beam computed tomography; DBM, demineralized bone matrix; GPP, gingivoperiosteoplasty; rhBMP, recombinant human bone morphogenetic protein; 2D, two dimensional; 3D, three dimensional
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Affiliation(s)
- Junhyung Kim
- Department of Plastic and Reconstructive Surgery, Keimyung University Dongsan Hospital, Keimyung University College of Medicine, Daegu, Korea
| | - Woonhyeok Jeong
- Department of Plastic and Reconstructive Surgery, Keimyung University Dongsan Hospital, Keimyung University College of Medicine, Daegu, Korea
- Correspondence: Woonhyeok Jeong Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea E-mail:
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10
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Doucet JC, Russell KA, Daskalogiannakis J, Mercado AM, Hathaway RR, Semb G, Shaw WC, Long RE. Early Secondary Alveolar Bone Grafting and Facial Growth of Patients with Complete Unilateral Cleft Lip and Palate. Cleft Palate Craniofac J 2022; 60:734-741. [PMID: 35171057 DOI: 10.1177/10556656221080990] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the craniofacial growth outcomes of early secondary alveolar bone grafting(ABG) around 6 years of age. DESIGN Retrospective cohort study. SETTING 1 North-American and 5 Northern-European cleft centers. SUBJECTS 33 subjects with CUCLP consecutively treated with secondary ABG around 6 years of age were compared to 105 subjects from 4 centers treated with late secondary ABG and 19 subjects from 1 center with primary ABG. METHODS Preorthodontic standardized lateral cephalometric radiographs taken after 12 years of age were traced and analyzed according to the Eurocleft Study protocol. Fourteen angular and two proportional measurements were performed. Measurement means from the Study Center(SC) were compared to 5 Northern-European centers using analysis of variance and Welch's modified t-tests, and P < .05 was considered statistically significant. RESULTS For the SC, the mean age ± SD at the time of bone graft was 5.85 ± 0.71 years and the mean age at the time of the lateral cephalogram was 13.4 ± 1.8 years. The sagittal maxillary prominence of the SC was favorably comparable to the 5 Northern-European centers. The mean SNA (78.1 ± 4.3) for the SC was significantly higher compared to 4 of the 5 Northern-European centers(all P < .05), and the mean ANB angle was comparable to 4 of the 5 centers. Similarly, the mean soft tissue ANB angle was not significantly different to the 5 centers. The soft tissue vertical proportions compared favorably to all 5 Northern-European centers(all P < .01). CONCLUSIONS Craniofacial growth outcomes of early secondary ABG around 6 years compare favorably to the outcomes of late secondary ABG.
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Affiliation(s)
- Jean-Charles Doucet
- Department of Oral and Maxillofacial Sciences, 3688Dalhousie University, Halifax, Canada.,Cleft Palate Team, 3682IWK Health Care Center, Halifax, Canada
| | - Kathleen A Russell
- Cleft Palate Team, 3682IWK Health Care Center, Halifax, Canada.,Division of Orthodontics, 3688Dalhousie University, Halifax, Canada
| | - John Daskalogiannakis
- Department of Orthodontics, University of Toronto, Toronto, Ontario, Canada.,Department of Dentistry, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ana M Mercado
- Division of Orthodontics, Ohio State University, Columbus, OH, USA
| | - Ronald R Hathaway
- Department of Orthodontics and Pediatric Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Gunvor Semb
- University of Manchester, Manchester, UK.,OsloCleft-CraniofacialCenter, Norway
| | | | - Ross E Long
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
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11
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Powell KK, Lewis P, Sesanto R, Waite PD. Does Early Secondary Alveolar Bone Grafting Influence Need for Additional Maxillary Advancement Procedures in Cleft Lip and Palate? Cleft Palate Craniofac J 2021; 59:1279-1285. [PMID: 34514855 DOI: 10.1177/10556656211042789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Kathlyn K Powell
- School of Dentistry, 83488University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paul Lewis
- School of Dentistry, 83488University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rae Sesanto
- School of Dentistry, 83488University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter D Waite
- School of Dentistry, 83488University of Alabama at Birmingham, Birmingham, AL, USA
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12
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Brudnicki A, Regulski PA, Sawicka E, Fudalej PS. Alveolar Volume Following Different Timings of Secondary Bone Grafting in Patients with Unilateral Cleft Lip and Palate. A Pilot Study. J Clin Med 2021; 10:jcm10163524. [PMID: 34441820 PMCID: PMC8396845 DOI: 10.3390/jcm10163524] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Andrzej Brudnicki
- Department of Maxillofacial Surgery, Clinic of Pediatric Surgery, Institute of Mother and Child, 01-211 Warsaw, Poland;
- Correspondence:
| | - Piotr A. Regulski
- Dentomaxillofacial Radiology Department, Medical University of Warsaw, 02-091 Warsaw, Poland;
- Center of Digital Science and Technology, Cardinal Stefan Wyszynski University, 01-815 Warsaw, Poland
| | - Ewa Sawicka
- Department of Maxillofacial Surgery, Clinic of Pediatric Surgery, Institute of Mother and Child, 01-211 Warsaw, Poland;
| | - Piotr S. Fudalej
- Department of Orthodontics and Dentofacial Orthopedics, School of Dental Medicine, University of Bern, 3012 Bern, Switzerland;
- Department of Orthodontics, Institute of Dentistry and Oral Sciences, Palacký University Olomouc, 779 00 Olomouc, Czech Republic
- Department of Orthodontics, Jagiellonian University, 31-155 Krakow, Poland
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13
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Stonehouse-Smith D, Beale V, Bellardie H. Radiographic outcome of secondary alveolar bone grafting in patients with alveolar clefts. Orthod Craniofac Res 2021; 25:128-133. [PMID: 34101345 DOI: 10.1111/ocr.12508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/29/2021] [Accepted: 06/03/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the outcome of secondary alveolar bone grafting (SABG) in a series of consecutive patients with clefts involving the alveolus. DESIGN AND SETTING Retrospective cohort study of consecutive operations performed between June 2011 and September 2016 by a single surgeon at a single United Kingdom cleft center. PARTICIPANTS A total of 160 patients with a cleft/s involving the alveolus, inclusive of syndromic patients and those with atypical facial clefts. INTERVENTIONS A standard protocol involved an oral hygiene program, pre-surgical orthodontics where necessary and autologous bone grafting from the iliac crest. MAIN OUTCOME MEASURE(S) The Kindelan bone-fill index was used to evaluate success using occlusal radiographs. Weighted Cohen's kappa coefficient was used as a measure of intra- and inter-rater agreement. Fisher's exact test was used to examine the effects of type of cleft, pre-surgical orthodontics or age at time of SABG on radiographic outcome. RESULTS There were 200 SABGs assessed. Mean age at time of SABG was 9.1 years old (SD 1.1) with 99% (n = 198) of grafts deemed successful. There were two failures where re-graft was performed successfully during the study period. A grade 1 outcome was achieved for 92.5% (n = 185) of grafts and this did not appear to be affected by type of cleft (P = .290), pre-surgical orthodontics (P = .380) or age at time of SABG (P = .081). CONCLUSIONS The high success rate reported in this study supports the favorable outcomes of a high-volume cleft surgeon. These findings can be used for comparative audit with similar units providing cleft care.
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Affiliation(s)
- Daniel Stonehouse-Smith
- Cleft Lip and Palate Unit, Royal Manchester Children's Hospital, Manchester, UK.,Department of Orthodontics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Victoria Beale
- Cleft Lip and Palate Unit, Royal Manchester Children's Hospital, Manchester, UK
| | - Haydn Bellardie
- Cleft Lip and Palate Unit, Royal Manchester Children's Hospital, Manchester, UK.,Faculty of Dentistry, Department of Orthodontics, University of the Western Cape, Cape Town, South Africa
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14
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Brudnicki A, Sawicka E, Fudalej PS. Maxillofacial morphology in post-pubertal patients with unilateral cleft lip and palate following early vs. late secondary alveolar bone grafting. J Craniomaxillofac Surg 2021; 49:809-814. [PMID: 33965325 DOI: 10.1016/j.jcms.2021.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/14/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022] Open
Abstract
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.
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Affiliation(s)
- Andrzej Brudnicki
- Department of Maxillofacial Surgery, Clinic of Pediatric Surgery, Institute of Mother and Child Warsaw, Poland.
| | - Ewa Sawicka
- Department of Maxillofacial Surgery, Clinic of Pediatric Surgery, Institute of Mother and Child Warsaw, Poland
| | - Piotr Stanisław Fudalej
- Institute of Dentistry and Oral Sciences, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic; Department of Orthodontics and Dentofacial Orthopedics, School of Dental Medicine, University of Bern, Switzerland; Department of Orthodontics, Institute of Dentistry, Jagiellonian University College of Medicine, Krakow, Poland
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15
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Skeletal and Dental Habilitation of Residual Alveolar and Maxillary Clefts. J Craniofac Surg 2021; 32:991-998. [PMID: 33481475 DOI: 10.1097/scs.0000000000007462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Management of residual clefts of the alveolus and maxilla requires the coordinated effort of multiple members of the craniofacial team including surgeon, orthodontist, and when teeth are hypoplastic or absent, the prosthodontist to achieve complete habilitation. Such cooperation among specialists begins early in the patient's life and continues through completion of care.Although numerous publications on this topic exist, few present definitive multidisciplinary reconstructive outcomes with longterm results. In this review paper, the authors present our comprehensive, multidisciplinary protocols, experience, and techniques as they have evolved with over 35 years of practice at our Craniofacial Center.Details of our updated protocols for each intervention and procedure, including our current thoughts on appropriate timing, follow up and advantages from the incorporation of current technologies are discussed. Close cooperation among specialists at all stages of care, the use of evolving technology, and adherence to, and modification where indicated, of time honored team protocols enables us to consistently achieve successful functional and esthetic outcomes, while minimizing complications.
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16
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Lowry CH, Long RE, Russell K, Giltner JQ, Weaver L, Mercado AM, Beals S, Beals P, Daskalogiannakis J, Hathaway RR, Doucet JC, Semb G, Shaw WC. The Effect of Earlier Bone Grafting, Prior to Orthodontic Treatment, on SWAG Ratings of Graft Outcomes. Cleft Palate Craniofac J 2020; 58:208-214. [PMID: 32812441 DOI: 10.1177/1055665620949433] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To compare the outcomes between 2 groups of patients with complete clefts treated with early secondary alveolar bone grafting (ABG) at 2 centers (5-7 years, before orthodontic intervention) and to a third group of patients treated at one of those centers (center 1) who had received later secondary ABG (8-10 years, after orthodontic intervention). DESIGN Blind retrospective analysis of cleft site radiographs using Americleft Standardized Way to Assess Grafts (SWAG) scale. PATIENTS A total of 99 patients with complete clefts from 2 North American cleft/craniofacial centers. INTERVENTIONS Secondary ABG representing 2 protocols: early grafting at a mean age of 6.6 years prior to any orthodontic intervention, and later grafting at a mean age of 10.2 years following pregrafting orthodontic intervention. MAIN OUTCOME MEASURES Using occlusal radiographs, the SWAG scale from 0 (failed graft) to 6 (ideal) was used. Six trained, calibrated raters scored each radiograph twice, with the average of the 2 ratings used as the final score. Reliability was assessed using the weighted κ statistic. The significance of differences between groups was determined using the Kruskal-Wallis test and Dunn test for pairwise comparisons. RESULTS Inter-rater reliability of SWAG method was good (0.631). Intra-rater reliability was excellent (0.817). There was a tendency for improved total graft outcome in the early grafted group from center 1 compared to the later grafted group with improvement being significantly different in only the coronal third of the early, preorthodontic grafted group. However, the difference was not statistically significant for the graft overall.
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Affiliation(s)
- Catherine H Lowry
- Department of Dental Medicine, Orthodontics, 6566Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Ross E Long
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
| | - Kathleen Russell
- Division of Orthodontics, Dalhousie University, Halifax, Nova Scotia, Canada.,Cleft Palate Team, IWK Health Centre, Halifax, Nova Scotia, Canada
| | | | - Lexi Weaver
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
| | - Ana M Mercado
- Division of Orthodontics, College of Dentistry, 2647The Ohio State University, Columbus, OH, USA
| | - Stephen Beals
- Barrow Cleft & Craniofacial Center, Phoenix, AZ, USA
| | | | - John Daskalogiannakis
- Department of Orthodontics, University of Toronto, Ontario, Canada.,Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronald R Hathaway
- Division of Plastic Surgery, Cincinnati Childrens Hospital, Cincinnati, OH, USA
| | - Jean-Charles Doucet
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA.,Department of Oral and Maxillofacial Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gunvor Semb
- University of Manchester, Manchester, United Kingdom.,OsloCleft-CraniofacialCenter, Norway
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17
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Pinheiro FHDSL, Drummond RJ, Frota CM, Bartzela TN, Dos Santos PB. Comparison of early and conventional autogenous secondary alveolar bone graft in children with cleft lip and palate: A systematic review. Orthod Craniofac Res 2020; 23:385-397. [PMID: 32446283 DOI: 10.1111/ocr.12394] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/29/2020] [Accepted: 05/16/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
| | - Robert John Drummond
- Division of Orthodontics, Department of Preventive Dental Science, Faculty of Dentistry, University of Manitoba, Winnipeg, MB, Canada
| | - Carolina Martins Frota
- Division of Orthodontics, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo, Bauru, Brazil
| | - Theodosia N Bartzela
- Department of Orthodontics, Orthopedics and Pediatric Dentistry, Charité - Universitätsmedizin Berlin, Berlin, Germany
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