A Multicenter Study Using the SWAG Scale to Compare Secondary Alveolar Bone Graft Outcomes for Patients with Cleft Lip and Palate

A national survey of current practice in pre-alveolar bone graft orthodontics in the United Kingdom

OBJECTIVE

To obtain an overview of current practice for pre-alveolar bone graft (pre-ABG) orthodontics at cleft centres across the United Kingdom.

DESIGN

Cross-sectional survey.

SETTING

Web-based.

METHODS

The survey was distributed online to UK orthodontic consultants undertaking cleft care and was piloted before use. The domains explored included level of experience, perceived benefits and concerns with undertaking pre-ABG orthodontics, types of appliances used and ABG outcomes.

RESULTS

A total of 38 consultant orthodontists responded, with a response rate of 56%. Pre-ABG orthodontics was performed most commonly (81.6%) in patients with a bilateral cleft lip and palate; however, 21.1% never performed it in any cleft phenotypes. The most common types of appliances used were fixed slow expanders and fixed appliances. No respondents reported poor ABG outcomes.

CONCLUSION

There was no clear protocol for providing pre-ABG orthodontic treatment, with wide variation across the UK. A variety of orthodontic treatment approaches are being undertaken, and the outcomes of ABGs remain successful. Multidisciplinary teams should have a holistic approach to patient care when deciding to perform pre-ABG orthodontics and involve patients in decision making. Future UK research should focus on additional secondary outcomes and determining a standardised approach to ensure best possible care is delivered.

Evaluation of platelet-rich fibrin versus collagen membrane for enhancing healing of secondary grafted alveolar cleft: a randomised controlled trial

The purpose of this study was to compare the efficiency of using autologous platelet-rich fibrin versus a resorbable collagen membrane in secondary alveolar bone grafting. Patients were randomly allocated to the three treatment groups: Group 1 - twelve children in whom the nasal layers of the alveolar clefts were repaired using autologous platelet-rich fibrin with autogenous chin bone; Group 2 - twelve children in whom the nasal layers of the alveolar clefts were repaired using bovine collagen membrane type I (Colla-D) with autogenous chin bone; and Group 3 - twelve children in whom the bony alveolar clefts were grafted with autogenous chin bone after construction of a watertight nasal floor had been completed. The study population comprised 36 patients with alveolar clefts, ranging in age from seven to 12 years. At the last follow-up period all groups had stable healing conditions and good radiological outcomes in terms of the alveolar bone height bordering the teeth (both mesially and distally) and the incorporation of grafting material with the surrounding bone. The use of either a PRF membrane and a collagen membrane as an interpositional layer between the nasal layer and the autogenous chin bone graft enhanced bone formation and density in alveolar clefts compared with the control group.

Evaluation of Radiographic Outcomes of Alveolar Graft Associated with Premaxillary Osteotomy Performed with rhBMP-2

OBJECTIVE

To evaluate the influence of filling material and timing of surgery on radiograph outcomes of alveolar grafting with premaxillary osteotomy. The null hypothesis was that radiographic outcomes would be similar with both rhBMP-2 (rhBMP-2G) and cancellous bone from the iliac crest (IG), regardless of the timing of surgery.

DESIGN

Cross-sectional study with consecutive sampling of 56 periapical or occlusal radiographs taken 12 months after surgery.

SETTING

A single tertiary craniofacial center.

PATIENTS/PARTICIPANTS

Twenty-eight patients with complete bilateral cleft lip and palate and mean age of 13 years. The individuals underwent bilateral alveolar grafting associated with premaxillary osteotomy (AG + PO) with rhBMP-2 or cancellous bone from the iliac crest.

INTERVENTIONS

Experienced maxillofacial surgeons used the same surgical technique in both groups. AG + PO were assigned as success or failure by 3 blinded raters based on modified Bergland and SWAG scales.

MAIN OUTCOME MEASURES

The influence of filling materials and timing of surgery on radiographic outcomes was verified by Fisher's exact test and chi-square test (P < .05).

RESULTS

There was no significance variation between the mean age of participants in the rhBMP-2G and IG (P = .471). Scales showed almost perfect reliability (agreement rate = 96.4%; K = 0.85). rhBMP-2G and IG had similar success rates with modified Bergland scale (85.7% and 82.1%) and SWAG scale (92.9% and 82.1%), respectively. However, only modified Bergland scale found influence of age on radiographic outcomes (P = .025).

CONCLUSIONS

AG + PO performed with rhBMP-2 and iliac crest bone showed similar radiographic success rates, regardless of the timing of surgery.

Inpatient versus Outpatient Alveolar Bone Grafting: A Nationwide Cost Analysis

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.

Evaluation of a high-fidelity cleft alveolar bone graft simulator

INTRODUCTION

Cleft alveolar bone graft surgery is technically challenging to perform as well as difficult to learn and teach. A high-fidelity cleft alveolar bone graft simulator was previously developed. However, further evaluation of the simulator is necessary to assess its efficacy.

METHODS

Two cleft simulation workshops were conducted in which participants were led through a simulated cleft alveolar bone graft. The first simulation workshop involved six plastic surgery trainees. The second workshop involved 43 practicing cleft surgeons. The participants were provided with a Likert-type questionnaire assessing the simulators' features, realism, and value as a training tool. The change in self-reported confidence was assessed by providing each participant with a pre- and post-simulation confidence questionnaire.

RESULTS

There was overall agreement in the realism of the simulators' features (average score of 4.67 and 3.80 out of 5 for the trainees and surgeons, respectively). There was overall agreement to strong agreement in the simulators value as a training tool (average score of 5 and 4.43 out of 5 for the trainees and surgeons, respectively). The self-reported confidence increased for all questionnaire items for both the trainees and surgeons. This was significant (p < 0.05) for five out of eight and all questionnaire items for the trainees and surgeons, respectively. The magnitude of the confidence increase was generally greater for less experienced participants.

CONCLUSION

The cleft alveolar bone graft simulator was found to be realistic and valuable as a training platform. Use of the simulator improved self-reported confidence in cleft alveolar bone graft surgery.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

The First Alveolar Bone Graft Simulator

Alveolar bone graft (ABG) surgery in cleft patients is technically challenging. The procedure requires design, dissection and release of soft tissue flaps to create a seal around the bone graft. In addition, visualization during the procedure is challenging within the confines of the cleft. These features make ABG surgery difficult to learn and teach, and it is, therefore, a suitable procedure for the use of a simulator. A high-fidelity cleft ABG simulator was developed using three-dimensional printing, polymer, and adhesive techniques. Simulated ABG surgery was performed by two expert cleft surgeons for a total of five simulation sessions to test the simulator's features and the ability to perform the critical steps of an ABG. ABG surgery was successfully performed on the simulator. The simulations involved interacting with realistic dissection planes as well as multi-layered synthetic soft (periosteum, mucosa, gingiva, adipose tissue) and hard (teeth, bone) tissue. The simulator allowed performance of cleft marginal incisions, dissection, and elevation of a muco-gingival-periosteal flap, creation of nasal upturned and palatal downturned flaps, nasal and palatal side closure, insertion of simulated bone graft material, and advancement of the muco-gingival-periosteal flap for closure of the anterior wall of the cleft. The ABG simulator allowed performance of the critical steps of ABG surgery. This is the first ABG simulator developed, which incorporates the features necessary to practice the procedure from start to finish.

Midpalatal suture bone repair after miniscrew-assisted rapid palatal expansion in adults

Background

Midpalatal suture (MPS) repair in growing patients after RPE has been previously reported. However, differences between young and adult patients for timing and pattern of MPS repair after rapid maxillary expansion are expected. The aim of this study was to evaluate the midpalatal suture repair pattern after miniscrew-assisted rapid palatal expansion (MARPE) in adult patients.

Materials and methods

The study included 21 patients (six males, 15 females) successfully treated with MARPE with a mean initial age of 29.1 years of age (SD = 8.0; range = 20.1–45.1). MPS repair was evaluated using maxillary axial and coronal sections derived from CBCT exams taken 16 months after the expansion (SD = 5.9). Objective and subjective assessments of MPS repair were performed. Objective assessments were performed measuring MPS bone density at anterior, median and posterior region of hard palate. Pre-expansion and post-retention bone density changes were evaluated using paired t tests (p < 0.05). Midpalatal suture bone repair was scored 0 to 3 considering, respectively, the complete absence of bone repair in the MPS, the repair of less than 50% of the MPS, the repair of more than 50% of the MPS and the complete repair of the MPS. Intra- and interexaminer reliability evaluation were assessed using Kappa coefficient.

Results

The objective evaluation showed a significant higher bone density at the pre-expansion stage in all palatal regions. The reliability of the subjective method was adequate with intra- and interexaminer agreements varying from 0.807 to 0.904. Scores 1, 2 and 3 were found in 19.05%, 38.09% and 42.86% of the sample, respectively. The most common region demonstrating absence of bone repair was the middle third. The anterior third of the midpalatal suture was repaired in all patients.

Conclusions

A decreased bone density was observed after the retention period when compared to pre-expansion stage. Most adult patients demonstrated incomplete repair of the midpalatal suture 16 months after MARPE. However, adequate bone repair covering more than half of the hard palate extension was observed in 80.95% of the patients.

Alveolar cleft bone grafting at different age periods

Relevance. Anatomical and functional disorders in congenital clefts may be various. Their severity depends on the cleft size and on the combination of a cleft lip with an alveolar cleft. Alveolar cleft bone grafting (ACBG) is one of the most important surgeries for patients with cleft lip and palate rehabilitation. The study aimed to analyze the results of alveolar cleft bone grafting in various age groups, summarizing the available data and supplementing them with our own experience.

Materials and methods. In our clinic, 488 patients of different ages (from 4 to 18 years old), including patients with bilateral clefts, underwent ACBG.

Results. The result analysis showed the time of surgery should depend not on the child's age but on the orthodontic preparation of the child for ACBG.

Conclusion. The literature data and our experience allowed us to develop indications for ACBG at different ages

Correlation between alveolar cleft morphology and the outcome of secondary alveolar bone grafting for unilateral cleft lip and palate

Background

Secondary alveolar bone grafting (SABG) is an integral part of the treatment for cleft lip and alveolus and cleft lip and palate. However, the outcome of SABG was not satisfactory as expected, factors that affecting the outcome were still controversial. The aims of this study were to summarize a new method for the classification of alveolar cleft morphology in patients with unilateral cleft lip and alveolus or unilateral cleft lip and palate, to evaluate the correlation between the morphology and SABG outcomes, to identify factors that might predict the outcomes.

Methods

The characteristics of the cleft morphologies of 120 patients who underwent SABG were observed using the preoperative Cone-Beam Computed Tomography (CBCT) images. 52 patients who had CBCT scans performed at least 6 months after SABG were included for the evaluation of outcomes. Both categorical and continuous evaluation methods were measured. Correlations between cleft morphology and SABG outcomes were assessed using the Pearson correlation coefficient in SPSS 27.0.0.

Results

A new method for the classification of cleft morphology was summarized:type I, prism type (labial defect size ≥ palatal defect size; nasal defect size ≥ occlusal defect size); type II, prism’ type (labial defect ≥ palatal defect; nasal defect < occlusal defect); type III, inverted prism type (palatal defect ≥ labial defect); type IV, funnel type (presented as a significantly narrow defect area in the middle towards the vertical dimension); and type V, undefinable (extremely irregular morphology can’t be defined as any of the above types). Categorical evaluation showed 8 failure, 11 poor, 12 moderate, and 21 good results, while the average bone filling rate was 59.24 ± 30.68%. There was a significant correlation between the cleft morphology and categorical/continuous evaluation outcome (p < 0.05).

Conclusion

The new method for the classification of alveolar cleft morphology summarized in this study was comprehensive and convenient for clinical application. Both categorical and continuous methods should be used for radiographic assessments in patients undergoing SABG. The chances of a successful procedure might be better when the patient has type I or IV morphology, in which the shape is like a funnel in the relatively palatal or occlusal area towards the vertical dimension. A relatively great amount of bone resorption was observed in most patients.

Trial registration Chinese clinical trial registry; registration number: ChiCTR2100054438.

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.

Early Secondary Alveolar Bone Grafting and Facial Growth of Patients with Complete Unilateral Cleft Lip and Palate

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.

Norwegian Orthodontists' Experience and Challenges With Treatment of Patients With Cleft Lip and Palate

Background:

Patients born with cleft lip and/or palate (CL/P) have orthodontic treatment challenges due to maxilla deficiency, malocclusions, and dental abnormalities. In Norway, orthodontic treatment is done by centralized CL/P teams. Due to traveling restrictions, this treatment might be done locally in the future. The experience of Norwegian community orthodontists in managing such patients has not been investigated previously.

Objective:

To assess Norwegian orthodontists’ management of patients with CL/P and need for further education.

Material and Methods:

All orthodontists in Norway were sent a questionnaire about their experience, challenges, and knowledge and asked about their need of further theoretical education and clinical training in the management of patients with CL/P.

Results:

Norwegian orthodontists’ standard of knowledge of CL/P treatment is adequate. However, few respondents have treated a high number of cleft patients. Eighty-six percent of the participants believed that treating CL/P patients involves challenges, such as time-consuming treatment and technical difficulties. Increased perceived need for more education was revealed among participants stated unpreparedness during education (4 folds), encountered challenges, and lack of knowledge (almost 3 folds).

Conclusions:

The study revealed that community orthodontists in Norway lack experience and acknowledged the challenges in treating patients with CL/P. Most of the respondents perceived a need for additional education and clinical training to treat CL/P patients competently. The findings suggested more focus on patients with CL/P management in the curricula and more collaboration between centralized CL/P teams and community orthodontists.

Radiographic outcome of secondary alveolar bone grafting in patients with alveolar clefts

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.

Skeletal and Dental Habilitation of Residual Alveolar and Maxillary Clefts

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.

Influence of bone-anchored maxillary protraction on secondary alveolar bone graft status in unilateral complete cleft lip and palate

INTRODUCTION

Our objective was to evaluate the effects of bone-anchored maxillary protraction (BAMP) on the status of the secondary alveolar bone graft in patients with unilateral complete cleft lip and palate (UCLP).

METHODS

The experimental group (EG) comprised 26 patients with UCLP, mean age of 11.9 years, submitted to secondary alveolar bone grafting (SABG) with recombinant bone morphogenetic protein, and BAMP therapy, using miniplate-borne Class III intermaxillary elastics. Cone beam computed tomography (CBCT) examinations were taken 6 months after SABG and before BAMP (T1) and after 18 months of BAMP therapy (T2). The control group (CG) was composed of 24 patients with UCLP submitted only to SABG with recombinant bone morphogenetic protein or autogenous bone from iliac crest without BAMP therapy, matched by initial age and sex with the EG. In the CG, CBCT examinations were performed 6 months (T1) and 12 months (T2) after SABG surgery. CBCT axial sections were analyzed using Garib scores in both time points. Intra- and intergroup comparisons were performed using Wilcoxon and Mann-Whitney tests, respectively (P <0.05).

RESULTS

No intergroup differences were found at T1 and T2. The EG showed significant improvement of graft status from T1 to T2 at the cervical and middle levels of the alveolar cleft. No significant interphase differences were found for graft scores in the CG.

CONCLUSIONS

Despite loads of intermaxillary elastics applied to the maxilla, no harm to the grafted alveolar bone was observed after BAMP therapy in patients with UCLP.

The Effect of Earlier Bone Grafting, Prior to Orthodontic Treatment, on SWAG Ratings of Graft Outcomes

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.

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

PURPOSE

Radiographic scales, based on plain radiographs, for the evaluation of alveolar cleft repair, have certain weaknesses and are thought to overestimate to some degree the success of the surgical intervention. The aim of this study was the presentation of a novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Patients treated with secondary osteoplasty for unilateral or bilateral alveolar cleft were evaluated using the Bergland and Enemark scales, as well as the novel success scale, which measures the bone height, the bone width and the level of the nasal floor.

RESULTS

A total of 44 patients with a total of 53 alveolar cleft sites were included. According to the new scale, 60% of the cases were defined as successful, with moderate (kappa = 0.511) or substantial (kappa = 0.718) agreement, between the new scale and the Bergland or Enemark scale, respectively. Statistically significant correlation was reported between the new success scale and the closure of space of the lateral incisor, the patient's age at surgery, the graft revision and the presence of residual fistula.

CONCLUSIONS

The novel success scale for evaluating alveolar cleft repair using CBCT takes into consideration all dimensions of the bony bridge. Future application is necessary for validation of its potential value.

Current methods for secondary alveolar bone grafting assessment in cleft lip and palate patients - A systematic review

INTRODUCTION

The development of 3D X-ray diagnostics has led to new methods for secondary alveolar bone grafting (SABG) assessment. The aim of this study was to collect and present literature from the years 2007-2018, and review on the current treatment outcome assessment methods for SABG.

MATERIALS AND METHODS

A systematic review of literature from 2007 to 2018 was carried out, following PRISMA guidelines. 426 records were identified after duplicate references had been removed. 25 articles were included in the review. The Cochrane Collaboration tool or the methodological index for non-randomized studies was used for quality evaluation.

RESULTS

Computed tomography and cone beam computed tomography were preferentially used for SABG treatment outcome verification. There were different assessment protocols. Due to the ways in which results were presented, methods were divided into five groups: linear measurements, volumetric measurements, density measurements, percentage ratios, and scales. There was only one randomized, controlled trial with high methodological quality.

CONCLUSIONS

1. Currently, 3D X-ray imaging is a standard treatment outcome verification method for SABG. 2. It is necessary to establish the required postoperative follow-up time for best SABG treatment outcome assessment. More prospective studies to assess bone graft outcomes after 6 months and 1 year are required.

Facial Growth of Patients With Complete Unilateral Cleft Lip and Palate Treated With Alveolar Bone Grafting at 6 Years

Objective:

To investigate the effect that alveolar bone grafting (ABG) around 6 years of age has on facial growth by assessing craniofacial growth outcomes.

Design:

Retrospective cohort study.

Setting:

North American cleft centers.

Participants:

A total of 33 children with complete unilateral cleft lip and palate who were consecutively treated with secondary ABG around 6 years of age were compared to 148 participants from 4 centers with late secondary ABG.

Methods:

Preorthodontic standardized lateral cephalometric radiographs were analyzed and traced according to the Americleft Study protocol. Sixteen angular and 2 proportional measurements were performed. The outcomes of all ABG were assessed using the Standardized Way to Assess Graft scale. Measurement means from the study center (SC) were compared to 4 North American centers using analysis of variance and Welch 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 comparable to the 4 other centers. The mean SNA (78.1 [4.3]) for the SC was significantly higher compared to one center that used primary bone grafting ( P = .03). The soft tissue mean ANB (3.52 [4.09]) for the SC was significantly lower compared to 3 of the centers.

Conclusions:

Early secondary ABG around 6 years of age did not result in reduced midface projection as assessed by SNA and thus did not compromise anterior maxillary growth.

Comparison of Reliability of Categorical and Continuous Scales for Radiographic Assessments of Bone Infill Following Secondary Alveolar Bone Grafting

OBJECTIVES

To investigate examiner reliability of scoring intraoral radiographs of bone infill following secondary bone grafting using a categorical scale (modified Kindelan Index) and a 10-cm visual analog scale (VAS). To investigate the level of clinical experience on the reliability of these assessments.

DESIGN

Retrospective study involving 10 clinicians of varying clinical experience who were blind to the patient's identity.

SETTING

All grafting was carried out within the New Zealand public hospital service.

PATIENTS

Fifty-eight grafts (48 UCLP and 5 BCLP) were assessed with 14 duplicated radiographs randomly added to the sample, making a total of 72 radiographs for assessment.

MAIN OUTCOME MEASURES

Weighted kappa was used for intra- and interrater examiner reliability for the categorical scale and correlations for the VAS.

RESULTS

Relatively poor intrarater examiner agreement for categorical scoring (median 0.46) was found. Clinicians with greater experience generally recording higher intrarater weighted kappa. The intrarater correlations for the continuous scale (median 0.89) suggest better consistency regardless of the level of experience. The interrater relationships were generally low, with an average of weighted kappa of 0.25 while the overall average VAS correlation was 0.49. For the majority of scorers, there was a relationship between the VAS and the Kindelan Index, with lower VAS scores related to worse Kindelan scores.

CONCLUSIONS

The use of a VAS produced better intra- and interexaminer reliability than the categorical Kindelan Index and was more consistent despite the level of clinical experience. Further evaluation of the validity of the VAS for the assessment of bone infill is warranted.

Reliability of the SWAG—The Standardized Way to Assess Grafts Method for Alveolar Bone Grafting in Patients with Cleft Lip and Palate

Objective

The objective of this study was to test a new method, a Standardized Way to Assess Grafts (SWAG), to rate alveolar bone graft (ABG) outcomes for patients with cleft lip and palate.

Design

This was a retrospective comparison using the SWAG scale.

Setting

This study took place in four cleft palate centers with different treatment protocols.

Methods

A total of 160 maxillary occlusal radiographs taken 3 to 18 months post-ABG for sequentially treated patients with cleft lip and palate were assessed using the SWAG scale. Radiographs were scanned, standardized, blinded, and rated by 6 calibrated orthodontists to assess vertical thirds, bony root coverage, and complete bony fill. All radiographs were rated twice, 24 hours apart, by the same raters.

Main Outcomes

Intra- and interrater reliabilities were assessed.

Results

Intrarater reliability was good to very good (.760; .652–.834), and interrater reliability was moderate to good (.606; .569–.681), comparable to previously published methods.

Conclusions

Rater reliabilities were shown to be comparable to or better than existing methods. The SWAG method was validated for ABG assessments in the mixed and permanent dentitions based on reliabilities in an intercenter outcome comparison.

Mesial and distal alveolar bone morphology in maxillary canines moved into the grafted alveolar cleft: Computed tomography evaluation

INTRODUCTION

The aims of this study were to qualitatively assess the mesial and distal alveolar bone of maxillary canines mesially moved to replace absent lateral incisors in patients with unilateral cleft lip and palate after secondary alveolar bone graft and to assess the reproducibility of the proposed cone-beam computed tomography (CBCT) method.

METHODS

The sample comprised CBCT examinations of 30 patients with unilateral cleft lip and palate from 1 center. CBCT images were taken at least 6 months after comprehensive orthodontic treatment. The noncleft side was used as the control group. Using axial sections, scores from 0 to 4 (bone absence to complete bone filling, respectively) were given to the mesial and distal alveolar bones of the maxillary canines. Interexaminer and intraexaminer reproducibility was assessed using kappa statistics. Intergroup comparisons were performed using Wilcoxon tests.

RESULTS

Interexaminer and intraexaminer agreement was excellent. Intergroup comparison identified smaller scores at the cervical and middle root levels of the cleft side mesial alveolar bone of the maxillary canines. At the cleft side, 85 mesial sites showed favorable scores (3 or 4); 1 had a score of 1, and 4 had scores of 2. At the distal surface, 78 sites were evaluated, and only 1 site received a score of 1. The noncleft side had scores of 4 for all sites.

CONCLUSIONS

The new CBCT scale showed good reproducibility. CBCT axial sections are reliable for a qualitative appraisal of alveolar bone in a grafted alveolar cleft. Mesial bone defects can be observed in maxillary canines moved into grafted areas after comprehensive orthodontic treatment, especially at the cervical root half.

[Application of team approach and key techniques of cleft lip and palate]

The development of an expert consensus based on specific domestic situations will provide practical guidance to the efforts aiming at improving cleft care in China. The team approach of twenty-one cleft centers were pooled together, covering pre-surgical orthopedics, primary surgical repair, orthodontic treatment, alveolar bone graft, secondary deformity correction, palatal fistulae repair, the diagnosis and treatment of velopharyngeal incompetence, speech therapy, otitis media management, and skeletal deformity correction. Agreement was achieved among the authors concerning the application of critical surgical and non-surgical techniques. The ambition of this consensus is to introduce more clinicians to the revolution of sequential treatment of clefts, and form the basis for a more comprehensive cleft care manual in the future.

The Americleft Project: A Comparison of Short- and Longer-Term Secondary Alveolar Bone Graft Outcomes in Two Centers Using the Standardized Way to Assess Grafts Scale

Objective

To compare length of follow-up and cleft site dental management on bone graft ratings from two centers.

Design

Blind retrospective analysis of cleft site radiographs and chart reviews for determination of cleft-site lateral incisor management.

Patients

A total of 78 consecutively grafted patients with complete clefts from two major cleft/craniofacial centers (43 from Center 1 and 35 from Center 2).

Interventions

Secondary iliac crest alveolar bone grafting, at a mean age of 9 years 9 months (Center 1: 9 years 7 months; Center 2: 10 years 0 month).

Main Outcome Measures

The Americleft Standardized Way to Assess Grafts scale from 0 ( failed graft) to 6 ( ideal) was used to rate graft outcome at two time points (T1, T2). Average T1 was 11 years 1 month of age, 1 year 3 months postgraft. Average T2 was 17 years 11 months of age, 8 years 0 months postgraft. Six trained and calibrated raters scored each radiograph twice. Reliability was calculated at T1 and T2 using weighted kappa. A paired Wilcoxon signed rank test ( P < .05) tested T1 and T2 differences for each center. A Kruskal-Wallis test was used to determine the significance of differences between centers at T1 and T2. Correlation tested whether T1 ratings predicted T2. Linear regression determined possible factors that might contribute to graft rating changes over time.

Results

Reliability was good at T1 and T2 (interrater = .713 and .701, respectively; intrarater = .790 and .805, respectively). Center 1 scores were significantly better than those from Center 2 at both T1 (5.21 versus 3.29) and T2 (5.18 versus 3.44). There was no statistical difference between T1 and T2 scores for either center; although, there was a greater chance of bone graft score improving with completion of canine eruption and substitution for missing lateral incisors.

Conclusions

Short-term ratings of graft outcomes identified significant differences between centers that persisted over time. Dental cleft-site management influenced final graft outcome.