Management of the Prominent Premaxilla in Bilateral Cleft Lip and Palate

Design and Objective

This study was designed to present our philosophy in managing the prominent premaxilla in patients with bilateral cleft lip and palate. Indications, contraindications, and the pre- and postoperative orthodontic role are defined.

Setting

Tertiary care, cleft palate and craniofacial center—academic institution.

Patients

Under review were four cases of bilateral cleft lip and palate presenting with prominent premaxilla and operated on by a single surgeon between 1996 and 2004.

Conclusion

With appropriate patient selection, bilateral alveolar bone grafting with premaxillary repositioning is a safe procedure and can produce good aesthetic and functional results.

Long-Term Study of Dental Implants Placed into Alveolar Cleft Sites

Objective:

To evaluate the long-term prognosis of dental implants placed into cleft sites after bone grafting in a relatively large number of cases in order to clarify the usefulness of the modality.

Patients:

Forty-seven patients with unilateral (dental, n = 32) or bilateral (n = 15) clefts of the alveolar process were included in this study.

Interventions:

A total of 71 implants, including smooth- or rough-surface titanium, and hydroxyapatite (HA)-coated implants, were placed after bone grafting from the anterior iliac crest and/or mandible. The placed implants were 13 to 15 mm in length.

Main outcome:

The follow-up period was from 21 to 120 months (average = 60 months). Implant survival rates were calculated as cumulative survival. Marginal bone loss (MBL) from the implant shoulder was examined, with statistical analyses performed on the influence of simultaneous bone graft and surface characteristics.

Results:

At the end of the clinical follow-up period, all implants except one were in situ and stable. Thus, the overall survival rate was 98.6% at the end of the first year and remained the same until the end of observation. Titanium implants with smooth surfaces had the lowest MBL with almost negligible regression slope, although some implants had relatively high MBL by the end of the first year.

Conclusions:

Implant therapy in the cleft site offers a reliable option for patients. Particular attention should be focused preoperatively on whether bone volume can provide primary implant stability.

Morbidity of Chin Bone Transplants Used for Reconstructing Alveolar Defects in Cleft Patients

Objective

The aim of this study was to evaluate the objective and subjective morbidity of symphyseal chin bone harvesting used for reconstruction of alveolar defects in young cleft patients.

Design

All patients who had undergone chin bone harvesting for alveolar cleft reconstruction in the period from 1992 through 2000 at the Department of Oral and Maxillofacial Surgery of the University Hospital Groningen, Groningen, The Netherlands, were invited to participate in this retrospective study. Patients’ acceptance, perioperative and postoperative morbidity were evaluated. A survey of the medical records was performed. In addition, the patients completed a questionnaire for their appreciation of the procedure. They were also subjected to a clinical and radiographic examination.

Patients

Thirty patients (21 males and 9 females; mean age 11.8 ± 3.6 years) participated in this study.

Results

Neither the medical records nor the experiences of the patients showed significant morbidity. The procedure was appreciated with 6.8 ± 3.5 (scale 0 to 10). Postoperative pain was scored as 1.2 ± 2.5 (scale 0 to 10). Three patients reported transient sensory disturbances at the donor site. Two patients showed a slight sensibility disorder in the symphyseal region. In three patients, an endodontic problem had developed in a lower incisor.

Conclusion

This study showed that chin bone harvesting for reconstructing alveolar cleft in young patients is a well-accepted procedure with low objective and subjective morbidity. Notwithstanding this low morbidity, the patients (and their parents) have to be informed about the risk of objective and subjective disturbances of the sensibility in the donor region and the risk of dental pulp necrosis.

Excessive Rapid Palatal Expansion with Latham Appliance for Distal Repositioning of Protruded Premaxilla in Bilateral Cleft Lip and Alveolus

Objective:

This article reports a case of bilateral cleft lip and alveolus (BCLA) for which excessive rapid palatal expansion with a Latham appliance was performed for preoperative alignment of the protruded premaxilla. Postoperative changes of maxillary width were investigated with serial plaster casts.

Patient and Results:

A 3-month-old girl presented with complete BCLA in which the premaxilla was markedly protruded. Preoperative alignment of the protruded premaxilla with a Latham appliance was planned to facilitate primary lip repair. The appliance was placed when the patient was 4.5 months old. The necessary palatal expansion was estimated to be 7.0 mm in order to move the premaxilla backward into the ideal position. After palatal expansion and posterior repositioning of the protruded premaxilla, the primary operation, including cheiloplasty and gingivoperiosteoplasty, was performed when the patient was 7 months old. Excessive maxillary expansion might be a cause of transverse maxillomandibular discrepancy. Measurement with serial plaster casts demonstrated that maxillary widths increased from 42.3 mm pretreatment to 49.0 mm after orthopedic treatment but relapsed markedly to 43.5 mm at 3 months after the primary operation. Therefore, the net change of maxillary widths was only 1.2 mm. After alignment of the protruded premaxilla, tension-free soft tissue repairs were performed, and a harmonious alveolar arch was obtained without change in maxillary width.

Conclusion:

These results indicate that this method is useful for preoperative management of BCLA with protruded premaxilla.

Assessment of Dental Arch Relationships in Japanese Patients with Unilateral Cleft Lip and Palate

Objective

Evaluation of the dental arch relationships of Japanese patients with unilateral cleft lip and palate (UCLP) from the orthodontic clinic of the University of Tokyo Hospital (UTH) compared with patients treated by the Oslo Cleft Team, Norway.

Design

Retrospective study and comparison with previous reports.

Materials

Dental models of 24 patients with UCLP in UTH taken before orthodontic treatment and before alveolar bone grafting were included. Surgeons in many hospitals performed primary surgeries. These models were matched for age and gender with 24 models from a consecutive series of patients treated by the Oslo Cleft Team as part of the Eurocran Good Practice Archive. A total of 48 models were evaluated.

Main Outcome Measure

Dental arch relationship was rated with the Goslon Yardstick. The strength of agreement of rating was assessed with weighted kappa statistics.

Results

Intra- and interexaminer agreements evaluated by weighted kappa statistics were high, indicating good reproducibility. Almost 60% of the patients in UTH were classified into poor or very poor categories, and the mean Goslon score was 3.50. These results show a contrast to those in Oslo and were the poorest in comparison with previous reports.

Conclusion

Dental arch relationships in patients with UCLP in UTH were poor. This seemed to be attributable to surgical procedures, but a factor of racial difference in the craniofacial morphology was also considered. Further intercenter research is required to clarify this point.

Assessment of Bone Resorption after Secondary Alveolar Bone Grafting Using Three-Dimensional Computed Tomography: A Three-Year Study

Objective:

Secondary bone grafting plays an important role in the dental rehabilitation of patients with clefts of the lip, alveolus, and palate. A major complication of this surgical technique is resorption of the grafted bone transplant. Conventional two-dimensional radiographs are often inconclusive and do not demonstrate the true deficit. The main objective of this study was to evaluate the amount and exact location of bone loss on the basis of three-dimensional models over a period of 3 years.

Design:

Twenty-four patients with unilateral cleft palate were included in this prospective study. Axial computed tomography scans of all patients were taken immediately preoperatively, and 1, 2, and 3 years postoperatively. Volumetric analysis was performed on three-dimensional models of the cleft defects and the bone bridges using three-dimensional computed tomography.

Interventions:

All patients were treated by secondary alveolar bone grafting prior to eruption of the permanent canine.

Results:

Extensive bone resorption was found in the bucco-palatal dimension of the alveolar portion of the transplant. The success rate of secondary bone grafting was high in cases of rapid orthodontic gap closures. The mean bone loss in the first year after surgery was 49.5%. The transplants remained almost constant in the following 2 years.

Conclusions:

Radiographic scales based on orthopantomography only evaluate the vertical dimension of the transplants. This study, however, showed that bone resorption in the transversal dimension is clearly underestimated with conventional two-dimensional radiographs.

Prepubertal Midface Growth in Unilateral Cleft Lip and Palate following Alveolar Molding and Gingivoperiosteoplasty

Objectives

To examine the long-term effect of nasoalveolar molding and gingivoperiosteoplasty (modified Millard type) on midface growth at prepuberty.

Procedures

In this retrospective study, 20 consecutive patients with a history of complete unilateral cleft lip and palate were evaluated. Ten patients had nasoalveolar molding and gingivoperiosteoplasty performed at lip closure; 10 control patients had nasoalveolar molding but no gingivoperiosteoplasty because of late start in treatment or poor compliance. A single surgeon (C.B.C.) performed all surgical procedures. Standardized lateral cephalometric radiographs were evaluated at two time periods: T1 at pre–bone-grafting age and T2 at prepuberty age. Superimposition and cephalometric analysis were undertaken to investigate the two groups. Two cephalometric reference planes, sella-nasion and basion-nasion, were used to assess the vertical and sagittal relations of the midface (ANS-PNS). The reference landmarks were procrustes fitted. The mean location and variance of ANS and PNS landmarks were computed. All results were analyzed by permutation test.

Results

No significant difference in mean location or variance of ANS-PNS in both vertical and sagittal planes at both T1 and T2 periods were found between the two groups (p > .05).

Conclusions

The results suggested that midface growth in sagittal or vertical planes (up to the age of 9 to 13 years) were not affected by presurgical alveolar molding and gingivoperiosteoplasty (Millard type).

Osteoplasty of the alveolar cleft defect

Cleft of lip, alveolar process and palate is the most common congenital defect affecting the face. It occurs at the time of early embryogenesis as a result of disturbed differentiation of the primordial cell layer and is associated with genetic and environmental factors. The most severe type of the defect is complete cleft of the lip, alveolar process and palate, unilateral or bilateral, which is accompanied by impaired breathing, sucking, swallowing, chewing, hearing and speaking. The treatment consists in the surgical reconnection (reconstruction) of the cleft anatomical structures and their formation to gain proper appearance, occlusal conditions and speech. The part of the surgical treatment is reconstruction of alveolar bone by means of autogenic spongy bone grafting (osteoplasty). The surgery performed at the stage of mixed dentition following an orthodontic treatment is a recognized standard management modality. Its effects provide stabilization of the dental arches fixed in the orthodontic treatment, possibility of growth of permanent teeth adjoining the cleft as well as separation of the nasal and oral cavities. The grafted bone becomes a platform for the collapsed base of the ala nasi and facilitates restoration of teeth loss. In the graft healing process the volume of the regenerated bone tissue is lower than the graft volume. Methods to augment the healed bone volume are being searched for, as this factor decides substantially on successful outcome of the surgery.

Comparison of restoratively projected and surgically acceptable virtual implant position for mandibular overdentures

PURPOSE

To compare differences between restoratively projected and surgically acceptable virtual implant positions at sites identified by cylindric radiopaque markers on diagnostic templates for implant-retained mandibular overdentures using cone beam computed tomography (CBCT).

MATERIALS AND METHODS

A retrospective chart audit of a CBCT database identified 77 subjects who had been imaged to assess the residual alveolar ridge in the completely edentulous mandible prior to implant placement for mandibular overdentures. Individuals had been scanned with a diagnostic template using cylindric markers to identify the restoratively derived locations and trajectories for implants. Qualitative and quantitative differences between restoratively projected and surgically acceptable positions on transaxial CBCT images were recorded using implant planning software based on a standard implant.

RESULTS

Only 6.4% of restoratively projected positions were within the criteria for surgically acceptable implant placement. However, most implant placement plans (77.9%) could be modified to fulfill surgically acceptable criteria. Of the projected implant positions, 15.7% were deemed inadvisable because of potential anatomical complications. Restoratively projected implant position was more likely to deviate buccally than lingually to the available residual alveolar ridge, as determined by CBCT. The mean angular deviation of the clinical prediction from ideal was 14.0 ± 5.5 degrees, the mean platform translation was 2.1 ± 1.3 mm, and the mean apex translation was 2.3 ± 1.5 mm. The average residual alveolar ridge reduction required in the posterior segment was 3.9 ± 2.5 mm.

CONCLUSION

The restoratively projected trajectory for implant placement determined by visual inspection, diagnostic casts, and panoramic radiography deviated from the surgically acceptable location determined using CBCT data sets.

Successful management of bleeding after dental procedures with application of blood stopper: a single center prospective trial

AIM

Ankaferd Blood Stopper (ABS), as an herbal complementary medicine, has been approved for the management of clinical hemorrhages in Turkey, including dental interventions. Basic, preclinical and clinical studies disclosed the settings of the topical hemostatic use of ABS. The aim of this study is therefore to assess the efficacy and safety of ABS as an antihemorrhagic agent in the bleedings associated with dental procedures in patients with normal and impaired hemostasis.

MATERIALS AND METHODS

ABS has been topically applied by homogeneously spraying to the 113 patients during dental interventions within its on-label indications. A median of 0.5 ml (IQR:0.5-1 ml) ABS was administered after tooth extraction with prolonged hemorrhages.

RESULTS

After the administration, bleeding stopped in less than 10 seconds in 59 (52.2%) patients, and below 22.5 seconds (IQR: 18, 8-30) in 54 patients (47.8%). A total of 141 procedures were performed in these 113 patients, and nearly 72.5 ml ABS was used with a total cost of 98 €.

CONCLUSION

ABS as a new herbal medicine was found to be an effective method for controlling bleeding related to dental procedures. No patient had wound infection and the healing process appeared to be normal. Topical ABS could be useful for the local hemostasis and wound healing in periodontal surgeries.

CLINICAL SIGNIFICANCE

In this prospective study ABS, for the first time, has demonstrated its potential for being an effective hemostatic agent for the management of bleedings due to dental procedures.

Implementation and validation of an extraction course using mannequin models for undergraduate dental students

OBJECTIVE

There is a gap in the education of dental undergraduate students between theoretical knowledge and the practical procedure of tooth extraction. It was the aim of this study to implement and validate an undergraduate course for oral extraction using mannequin models, in order to enhance practical competence in this field of dentistry.

MATERIAL AND METHODS

A one-term oral extraction course was implemented as part of the oral surgery curriculum for undergraduate dental students, including 4 h of theoretical education, followed by 4 h of practical training in tooth extraction on mannequin models, with the students divided into small groups. Forty-nine students attending this extraction course were asked to validate their training in dental extraction using a questionnaire (TRIL-mod; University of Trier, Trier, Germany). The students' practical competence in oral extraction was assessed by a senior supervisor at the end of the course, using a standardized checklist.

RESULTS

All questionnaires were returned. Overall, the course was rated with an average score of 4.7 (rating range: 1-6; 1 = worst/6 = best). The assessment of practical skills yielded a successful and complete performance of tooth extraction by 94% of the students.

CONCLUSIONS

A tooth extraction course using a mannequin model is appreciated by dental students and can achieve a sufficient level of competence in tooth extraction with reasonable educational efforts.

Periodontal surgery associated with odontoplasty in the esthetic functional rehabilitation of a fractured anterior tooth

Anterior dental fractures often require a multidisciplinary approach. This article presents a case in which an extensive fracture with palatal biological width invasion was treated successfully through clinical crown lengthening with odontoplasty. This procedure was a simple direct technique that restored the tooth without damaging the dental esthetics, the gingival contour, or the papillae.

[The effect of transversus abdominis plane block for pediatric patients receiving bone graft to the alveolar cleft]

BACKGROUND

Transversus abdominis plane block (TAP block) is useful for lower abdominal operations. Recently, ultrasound guided nerve block has been performed with ultrasound scanning.

METHODS

We investigated the effectiveness of TAP block in 64 pediatric patients (aged 5-12 years, F/M = 21/43) receiving bone graft from the ilium to the alveolar cleft. We compared the dosages for postoperative analgesics between the groups of TAP block and non-TAP block.

RESULTS

In the TAP block group, the frequency of using the postoperative analgesics was lower compared with non TAP block group (P < 0.05).

CONCLUSIONS

We concluded that TAP block was effective in pediatric patients receiving bone graft to the alveolar cleft.

Orthognathic correction of a craniofacial deformity in a patient with a mutilated dentition: a case report

Orthognathic surgery is routinely performed for patients with dentofacial deformity and has been conducted for more than 100 years (1). Orthognathic Surgery is a functional and esthetic surgery that affects patients self perception. Patients have noted an improvement in their facial appearance after orthognathic surgery that was associated with improvement in psychosocial adjustments (2). When the decision to move both the maxilla and the mandible is made, there are numerous variables to be considered. Among these variables are the stability of double jaw surgery, improving the masticatory function of the patient and lastly, the esthetic result. Past studies have also looked at patient concerns including temporomandibular joint symptoms, speech difficulties and problems with mastication. In one study by Rivera and colleagues who studied 143 patients pre-operatively found 71 pecent with esthetic concerns (3), 47 percent had functional concerns and 28 percent had temporomandibular joint concerns. Traditional treatment planning for two-jaw surgery uses the condyle as the point of rotation with the mandibular occlusal plane being used as a template for setting the maxillary teeth (4). This approach, which allows clockwise and counterclockwise rotation of the mandible gives stable skeletal results. Recent studies appear to indicate that long term stability is achieved mainly when rigid fixation is employed. Orthognathic surgery is only one part of the process to correct a dentofacial deformity. The process starts with the initial diagnosis, followed by a treatment plan and then patient consent. Treatment generally begins with a dental assessment to correct decay, followed by orthodontic decompensation in preparation for surgical intervention. Orthognathic surgery is followed by postoperative orthodontia to maximize the occlusal relationship. This process underscores the skill and detailed communication between orthodontist and oral surgeon, and emphasizes the crucial aspect of team approach in such complex surgical cases. We present here a report on a patient who had a mutilated dentition both in the maxilla and mandible along with a craniofacial deformity.

Multidisciplinary treatment of a fractured root: a case report

AIM

To describe the orthodontic, periodontal and prosthetic management of a case with a 3 mm root fracture below the crest of the alveolar bone.

METHODS

The root was extruded and periodontal surgery carried out to improve aesthetics and dental function.

CONCLUSION

A multidisciplinary approach to the management of dental root fractures is necessary for successful treatment.

The role of endosseous implants in the management of alveolar clefts

In individuals with cleft lip and palate, there is a high prevalence of hypodontia, particularly of the maxillary lateral incisor on the cleft side. The edentulous space in patients with a repaired alveolar cleft was traditionally treated with a fixed or removable partial denture, but this approach is not optimal. The purpose of this paper was to review the dental literature for infant orthopedic treatment, timing of alveolar bone grafting, timing of implant placement, and type of implants used in individuals with repaired alveolar clefts. There seems to be a consensus in the literature that the optimal timing for initial secondary alveolar bone grafting is between 8 and 11 years of age. Implants cannot be placed this early but should be placed within 6 months of augmentation bone grafting to avoid resorption of the grafted area. Longer implants--those at least 13 mm in length--reportedly have a higher survival rate compared to shorter implants. Other implant parameters such as surface characteristics and diameter do not seem to influence significantly the long-term longevity of implants placed into grafted alveolar clefts.

Periodontal maintenance therapy: an integral part of dental practice. Case reports on three periodontally involved patients

Periodontal maintenance therapy is an integral aspect of any general dental or specialist practice. Numerous studies have indicated that periodontal therapy in the absence of a carefully designed maintenance program invariably results in the relapse of the disease condition. Accordingly, dental practices that provide periodontal care without a maintenance program deal with significant patient management and disease management issues. In this article, three cases are presented with varying levels of disease severity but all sharing the common trait of having being enrolled in a good maintenance program with positive treatment outcomes.

Orthodontic treatment of cleft lip and alveolus using secondary autogenous cancellous bone grafting: a case report

AIM

This paper concerns orthodontic alignment of the maxillary lateral incisor on the cleft side of a lip and alveolar cleft patient after a secondary autogenous cancellous bone graft at the late stage of mixed dentition.

SUBJECT AND TREATMENT

The patient was a Japanese girl 9 years 7 months of age who presented at the authors' clinic with a repaired lip and alveolar cleft and an incisor crossbite. At 12 years of age, a secondary bone graft of the alveolar ridge was performed using bone harvested from the iliac crest. At 14 years 7 months of age, a conventional fixed appliance was placed.

RESULTS

The lateral incisor on the cleft side was brought to the line of occlusion by orthodontic alignment. A Class I molar relationship on both sides and a satisfactory facial profile were achieved. After a 2-year retention period, the occlusion and esthetics were maintained. Five years after grafting, however, a satisfactory bone level was not achieved due to positioning of the root of the lateral incisor, which was not completely upright in the bone graft area due to root tipping.

Treatment of severe bimaxillary protrusion with miniscrew anchorage: treatment and complications

BACKGROUND

Problems involving excessive face height and severe bimaxillary protrusion are usually treated with orthognathic surgery. When this form of treatment is rejected, retraction and intrusion of the anterior teeth using skeletal anchorage afforded by miniscrews may be employed.

AIMS

To describe the treatment of severe bimaxillary protrusion with the aid of miniscrews and to discuss the complications encountered during treatment.

METHODS

Following extraction of the four first premolars, miniscrews were placed bilaterally in both jaws to permit maximum retraction of the anterior teeth, and intrusion of the posterior and upper anterior teeth.

RESULTS

The upper incisors were retracted 12 mm and intruded 5 mm over 20 months. The mandible rotated forward and upward, the face height reduced and the facial aesthetics improved. During treatment an irregular ridge of bone developed labial to the upper incisors, bone was deposited in the incisive fossae and the apices of the upper incisors were resorbed. An alveoloplasty was carried out to recontour the labial bone and the incisive fossae.

CONCLUSIONS

Absolute anchorage provided by miniscrews may become an effective alternative to orthognathic surgery for treatment of severe bimaxillary protrusion. During extensive retraction, the teeth may contact structures not normally encountered during conventional orthodontic treatment.

Simple preservation of a maxillary extraction socket using beta-tricalcium phosphate with type I collagen: preliminary clinical and histomorphometric observations

Alveolar atrophy following tooth extraction remains a challenge for future dental implant placement. Immediate implant placement and postextraction alveolar preservation are 2 methods that are used to prevent significant postextraction bone loss. In this article, we report the management of a maxillary tooth extraction socket using an alveolar preservation technique involving placement of a cone of beta-tricalcium phosphate (beta -TCP) combined with type I collagen without the use of barrier membranes or flap surgery. Clinical examination revealed solid new bone formation 9 months after the procedure. At the time of implant placement, histomorphometric analysis of the biopsied bone showed that it contained 62.6% mineralized bone, 21.1% bone marrow and 16.3% residual beta -TCP graft. The healed bone was able to support subsequent dental implant placement and loading.

Regional odontodysplasia: report of a case in the mandible crossing the midline

AIM

This report presents an unusual case of regional odontodysplasia (RO) in the mandible which crosses the midline along with its clinical management.

BACKGROUND

RO is an uncommon, nonhereditary unilateral developmental anomaly involving the dental hard tissues, most frequently affecting the maxillary teeth.

REPORT

RO was diagnosed in a 12-year-old. The dysplastic teeth were the mandibular canines, lateral incisors, central incisors, and the right premolars. The treatment was extraction of the affected teeth followed by provisory prosthetic rehabilitation.

SUMMARY

The etiology of RO remains obscure. In this case a possible association with pre-natal trauma is suspected. The literature is not unanimous as to the management of RO. Nevertheless, the presence of a dental abscess is an indication for extraction. Since general bone quality is not affected, a provisory prosthesis was fabricated as the patient waits for future implant rehabilitation. The executed treatment met the expectations of the patient and her mother as it improved the patient's masticatory function, esthetics, and quality of life.

CLINICAL SIGNIFICANCE

The general practitioner must be prepared to deal with different situations in the dental office. The diagnosis of RO relies mainly on clinical and radiographic findings, and its treatment depends on the affected teeth, the severity of the dysplasia, the presence of infection, and the patient's age.

Alveolar cleft closure by distraction osteogenesis with skeletal anchorage during consolidation

Intraoral distraction osteogenesis (DO) has been widely used for the reconstruction of various dentoalveolar defects. However, its use in the management of alveolar clefts is relatively new. This method allows the closure of the cleft via the regeneration of new alveolar bone and attached gingiva through the distraction of a dento-osseous segment. It eliminates the need for a donor site for autogenous bone grafting and possible graft failure. However, the relatively long consolidation period required for the use of intraoral DO devices may result in soft tissue irritation that would compromise patient cooperation, especially in children. In the case presented, the intraoral DO technique was used for the treatment of a unilateral residual alveolar cleft and an implant was subsequently placed in the regenerated bone. A miniplate was also placed to serve as a skeletal anchor to enable the early removal of the distractor device. The distractor was removed before the beginning of the consolidation phase.

Repair of alveolar cleft defects: reduced morbidity with bone marrow stem cells in a resorbable matrix

Harvest of the autogenous iliac crest bone graft for an alveolar cleft defect (the gold standard) may cause short- and long-term pain and sensory disturbances. To determine if a tissue engineering technique with similar bone healing results offered decreased morbidity, we compared techniques for postoperative donor site pain. Traditional iliac crest bone graft had more donor site complications compared with both tissue engineering and minimally invasive iliac crest bone graft. With donor site pain, traditional had the most patients with pain and tissue engineering had the least patients with pain at all time points. The mean pain score, including both intensity and pain frequency, was greatest at all time points in traditional and least at all time points in tissue engineering. Closure of alveolar cleft defects with a resorbable collagen sponge and bone marrow stem cells resulted in reduced donor site morbidity and decreased donor site pain intensity and frequency.

Sagittal growth of the facial skeleton of 6-year-old children with a complete unilateral cleft of lip, alveolus and palate treated with two different protocols

OBJECTIVE

The purpose of the study was to compare sagittal growth of the facial skeleton of 6-year-old children treated in two cleft centres with different surgical protocols.

MATERIAL AND METHODS

Each group consisted of 20 consecutive non-syndromic children with complete unilateral cleft lip, alveolus and palate. They all had presurgical orthopaedics with a passive plate and external strapping until lip repair. Centre 1 had lip repair at the age of 3 months and one stage palatal closure at the age of 1 year. Closure of the alveolar cleft was planned at 9 years with bone grafting. In centre 2 lip repair was performed at the age of 6 months, soft palate repair at 12 months and hard palate repair together with mucoperiosteal closure of the alveolar cleft at the age of 30 months. At the time of investigation, the children from both centres had not received any postoperative orthodontic treatment. Sagittal growth was evaluated on lateral cephalograms using the angles SNA, SNB, ANB and SNPg. For control, Droschl standards were used. The Mann-Whitney U test was used for statistical analysis.

RESULTS

There was no statistically significant difference in SNA, SNB, ANB and SNPg between the centres at the age of 6 years. There were no children with a class III jaw relationship. The sagittal dimensions were close to the values of non-cleft control persons (Droschl standards).

CONCLUSION

There was considerable similar sagittal growth of the facial skeleton in both centres which has not been affected by the different surgical protocols so far. A final evaluation should be delayed until the growth of the facial skeleton is complete.

Les séquelles maxillaires dans les fentes labioalvéolopalatovélaires. Prise en charge orthodontique

Routine othodontic management is unavoidable in all patients with cleft lip and palate after primary surgery. This management combines dental arch alignment with maxillary expansion of the lesser fragment before alveolar bone grafting. To treat dental arch asymmetry, the space of the missing lateral incisor is preserved until the age of dental implant. Otherwise, dento-orthopedic treatment attempts to normalize transversal dental dimension once alveolar bone grafting is done in order to prepare the surgical advancement of the maxilla.

Clinical crown lengthening in the esthetic zone

Periodontal surgical procedures consisting of gingival flaps and osseous recontouring are indicated for crown lengthening of several contiguous teeth in the esthetic zone; both in cases where restorations are required and in cases where no restorations are planned, such as in patients with excessive gingival display due to altered passive eruption. Forced tooth eruption via orthodontic extrusion is the technique of choice when clinical crown lengthening is necessary on isolated teeth in the esthetic zone.

Preserving the Socket Dimensions With Bone Grafting in Single Sites: An Esthetic Surgical Approach When Planning Delayed Implant Placement

Recent advancements in barrier membranes, bone grafting substitutes, and surgical techniques have led to a predictable arsenal of treatment methods for clinicians who practice implant dentistry. The contemporary clinician is supplied with proven knowledge, substantiated materials, and instrument inventory that allows implant placement in cases that used to be reserved for the specialist in the past because of their complexity. Nowadays, postextraction alveolar ridge maintenance can be a predictable procedure and can certainly aid the clinician in preventing ridge collapse, thereby allowing for implant placement in a position that satisfies esthetics and function. Extraction socket maintenance for future implant therapy does not rule out immediate implant placement but rather provides an additional option when treatment planning implant patients. This article will focus on the concept of extraction socket preservation using regenerative materials. It will describe a technique suggested by the authors to resist bone resorption and soft tissue shrinkage following tooth extraction.

Advanced concepts in implant dentistry: creating the "aesthetic site foundation"

To obtain optimal and predictable aesthetics, deficiencies caused by soft and particularly hard tissue loss can be managed by various methods, such as orthodontic tooth eruption, socket preservation, and guided bone regeneration. However, in complex cases, these methods are often insufficient. Here, the authors introduce advanced concepts in aesthetic implant dentistry, such as "Aesthetic Site Foundation", "Aesthetic Guided Bone Regeneration" and "Implant Rectangle" that will guide the clinician in the quest to optimal aesthetic outcomes.

Alveolar Bone Formation in Patients with Unilateral and Bilateral Cleft Lip and Palate after Early Secondary Gingivoalveoloplasty: Long-Term Results

BACKGROUND

The Milan surgical protocol includes the use of an early secondary gingivoalveoloplasty together with hard palate closure at 18 to 36 months, to avoid later bone grafting. The goal of this study was to evaluate the long-term quality of ossification in patients who have undergone early secondary gingivoalveoloplasty.

METHODS

The samples consisted of panoramic radiographs of 87 unilateral cleft lip-cleft palate and 29 bilateral cleft lip-cleft palate patients. The records available allowed for a longitudinal and a cross-sectional evaluation of the ossification in the cleft area. Alveolar bridging was assessed using a modified Bergland's scoring system. Nasal area ossification and canine inclination were each given three different qualitative scores.

RESULTS

The alveolar bridging noted was type I (71.7 percent), type II (23.5 percent), and type III (4.8 percent) in the whole sample of unilateral and bilateral cleft lip-cleft palate patients. No type IV ossification was found. Longitudinal analysis showed that approximately one-fourth of the cleft sites improved after permanent tooth eruption, and very few worsened. An evaluation of permanent dentition in a group of 27 unilateral and nine bilateral cleft lip-cleft palate patients (mean age, 14.8 +/- 2.0 years) showed that 15.5 percent of the whole sample had canine retention and 4.4 percent of the whole sample had to be surgically exposed.

CONCLUSIONS

Early secondary gingivoalveoloplasty seems to allow for adequate ossification in both the alveolar and the nasal regions. Permanent tooth eruption occurs at a normal rate. None of the patients has required a secondary alveolar bone graft.

Therapy of peri-implantitis with resective surgery. A 3-year clinical trial on rough screw-shaped oral implants. Part II: radiographic outcome

OBJECTIVES

This clinical study on therapy of peri-implantitis aimed to compare the marginal bone loss of implants treated with different surgical approaches: implantoplasty and peri-implant resective surgery only.

MATERIAL AND METHODS

Over a period of 6 years, 10 patients (20 implants) were treated with implantoplasty (test group) and 9 had resective surgery (control group). A computerized analysis of radiographs was performed to calculate marginal bone loss (MBL) values mesial and distal to the implants. The measurement system was set by means of known implant sizes. Data on MBL were collected at the time of peri-implantitis diagnosis, 1, 2 and 3 years after surgery.

RESULTS

There was no difference between the mean MBL values three years after implantoplasty in the test group: 0 and 0.01 mm of MBL mesial and distal to the implant were found (P>0.05). Conversely, the mean MBL values recorded in the control group were statistically different: 1.44 and 1.54 mm of MBL mesial and distal to the implant were found (P<0.05) 3 years after resective surgery. Moreover, the variation of peri-implant marginal bone after peri-implantitis surgical treatment was significantly lower in the test group than in the control group (P<0.05).

CONCLUSIONS

The results of this radiographic research suggested that implantoplasty was an effective treatment of peri-implant infections and peri-implantitis progression.

Bone grafting with platelet-rich plasma in alveolar cleft. Case report

Bone grafting of the alveolus has become an essential part of the contemporary surgical management of oral clefts. The benefits of this procedure are the stabilization of the maxillary arch, elimination of oronasal fistulae, the reconstruction of the soft tissue nasal base support, creation of bony support for subsequent tooth eruption or, when they are not present or not preserved, for implants application. The authors show a case of bone grafting with the aid of platelet-rich plasma (PRP). Because of the difficulties due to the oral cleft and to its surgical reparation (big size of bone defect, hard scars and sclerotic soft tissue) the authors decided to add PRP to a bone graft taken from the chin. PRP contains a high concentration of growth factors and is able to stimulate both wound and bone regeneration. Infact, the authors have observed very good results both in bone integration and in soft tissue reparation.

Synthetic, pure-phase beta-tricalcium phosphate ceramic granules (Cerasorb®) for bone regeneration in the reconstructive surgery of the jaws

The aim of this study was to investigate the long-term effect of the ceramic beta-tricalcium phosphate (beta-TCP) at different sites of alveolar reconstruction and to evaluate its properties. From 1997 to 2002, beta-TCP was implanted as bone substitute in 152 patients using a standardized study protocol. Main indications were the filling of large mandibular cysts (n=52), secondary and tertiary alveolar cleft grafting (n=38), periodontal defects (n=24) and maxillary sinus floor augmentation (n=16). For defects exceeding 2cm in diameter, beta-TCP was combined with autologous bone taken from the retromolar area, the maxillary tuberosity or the chin region. A radiological, clinical and ultrasonographical examination was carried out 4, 12 and 52 weeks postoperative. In 16 cases, biopsies were taken after 12 months indicating complete bony regeneration. While wound-healing disturbances occurred in 9.2% of cases, partial loss of the bone substitute material was found in 5.9%, while total loss occurred in only 2%. Complete radiological replacement of beta-TCP by autologous bone was found after approximately 12 months, indicating its osteoconductive properties. Because of its versatility, low complication rate and good long-term results, synthetic, pure-phase beta-TCP is a suitable material for the filling of bone defects in the alveolar region.

Clinical use of the Er,Cr: YSGG laser for osseous crown lengthening: redefining the standard of care

To design the optimal outcome for a patient during aesthetic enhancement, the restorative dentist must seek to create a symmetrical and harmonious relationship between the lips, gingival architecture, and the positions of the natural dentate forms. In the author's experience, the Er,Cr: YSGG laser has been a useful adjunct for performing aesthetic surgical crown lengthening procedures. This article will highlight the associated biological principles and demonstrate techniques for the application of this laser in closed and open crown lengthening procedures.

LEARNING OBJECTIVES

This article demonstrates the use of the Er,Cr: YSGG laser for osseous crown lengthening . Upon reading this article, the reader should have: Enhanced awareness of criteria for developing a biologically stable free gingival margin. Greater familiarity with the open and closed crown lengthening procedures, including case selection and surgical approaches.

Assessment of Cleft Lip and Palate Patients Treated With Presurgical Orthopedic Correction and Either Primary Bone Grafts, Gingivoperiosteoplasty, or Without Alveolar Grafting Procedures

The effects of alveolar grafting on the development of the craniofacial complex have been reported by numerous investigators. The reported results vary in the literature from significant to very little impediment of maxillary growth. The present work evaluates and compares facial form at age six years in complete unilateral cleft lip and palate patients treated with presurgical orthopedic correction and primary reconstruction with (1) primary bone grafts (n = 14), (2) gingivoperiosteoplasty (n = II), or (3) without alveolar grafting procedures at the time of lip repair (n = 13). The cohort groups were analyzed with a one-way analysis of variance (ANOV A). Statistical analysis revealed significant differences between the three groups for only one of the 12 parameters analyzed. The primary bone grafted group demonstrated less vertical descent-of the anterior maxilla compared to the gingivoperiosteoplasty and non-grafted groups (P = .0027).

Stability of maxillary surgical movement in unilateral cleft lip and palate with preceding alveolar bone grafting

OBJECTIVE

To evaluate the long-term three-dimensional stability of Le Fort I maxillary osteotomy in patients with unilateral cleft lip and palate (CLP) who had preceding alveolar bone grafting.

DESIGN

Analysis of prospectively collected data.

SETTING

University teaching hospital and postgraduate training center.

SUBJECTS

Thirty consecutive patients with unilateral cleft lip and palate, who underwent the procedure between 1990 and 1999, satisfied the inclusion criteria and had complete records. There were 9 males and 21 females, with an age range of 14 to 28 years (mean, 18 years), and follow-up range of 12 to 66 months (mean, 62 months).

METHODS

Cephalometric and study cast analyses using pre- and postoperative records (3, 6, 12, 24, and 36 months). Evaluation of surgical movement and postsurgical change at all above time intervals was carried out to determine stability of surgical maxillary movement in the horizontal and vertical planes and to identify rotational and transverse relapse.

RESULTS

Total relapse of surgical movement was 31% in the horizontal plane and 52% in the vertical plane, as well as 30% rotational. Relapse correlated with extent of surgical movement, and most relapse occurred in the first 6 months after surgery. No significant transverse relapse was documented.

CONCLUSION

Alveolar bone grafting prior to osteotomy stabilizes the transverse dimension of the dental arch, but does not improve horizontal, vertical, or rotational relapse, which remains significant. Correlation of relapse with extent of surgical movement does suggest that planned over-correction is a reasonable option.

A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots

The objective of this investigation was to determine the fate of thin buccal bone encasing the prominent roots of maxillary anterior teeth following extraction. Resorption of the buccal plate compromises the morphology of the localized edentulous ridge and makes it challenging to place an implant in the optimal position for prosthetic restoration. In addition, the use of Bio-Oss as a bone filler to maintain the form of the edentulous ridge was evaluated. Nine patients were selected for the extraction of 36 maxillary anterior teeth. Nineteen extraction sockets received Bio-Oss, and seventeen sockets received no osteogenic material. All sites were completely covered with soft tissue at the conclusion of surgery. Computerized tomographic scans were made immediately following extraction and then at 30 to 90 days after healing so as to assess the fate of the buccal plates and resultant form of the edentulous sites. The results were assessed by an independent radiologist, with a crest width of 6 mm regarded as sufficient to place an implant. Those sockets treated with Bio-Oss demonstrated a loss of less than 20% of the buccal plate in 15 of 19 test sites (79%). In contrast, 12 of 17 control sockets (71%) demonstrated a loss of more than 20% of the buccal plate. In conclusion, the Bio-Oss test sites outperformed the control sites by a significant margin. No investigator was able to predict which site would be successful without the grafting material even though all were experienced clinicians. This leads to the conclusion that a patient has a significant benefit from receiving grafting materials at the time of extraction.

Case report: surgeon and orthodontist work together from patient's birth

This case report presents one of the initial participants of a new treatment protocol started in 1965 for children born with complete clefts of the lip, alveolus, and palate at Children's Memorial Hospital, Chicago, USA. The surgeon and orthodontist worked together and in tandem from the time of the patient's birth. The protocol involves lip and palate closure, along with the placement of a passive maxillary prosthesis and minimal primary osteoplasty to the alveolus to help stabilize the maxillary segments. This case is noteworthy in that the patient had a number of congenitally missing teeth, and treatment required moving a tooth into and through an area originally cleft. The patient is now 40 years of age. Intra- and extraoral photographs, cephalometric radiographs, occlusal dental radiographs, and dental casts through the treatment stages are presented.

Review of the UCL management of patients with cleft lip and palate

We describe the way our multidisciplinary team manages cleft lips and palates at our centre at the Catholic University of Louvain. Since 1987, we have opted for the neonatal repair of the cleft lip and nose, and closure of the cleft palate at three months of age. Multidisciplinary follow-up then takes place to detect and correct the sequellae. The children are seen once a year by a plastic surgeon, an otorhinolaryngologist, a maxillofacial surgeon, a speech therapist, an audiologist, and an orthodontist. Secondary corrections are scheduled depending on functional, aesthetic, and psychological requirements.

Treatment protocol for unilateral cleft lip and palate patients: questioned by two case reports

BACKGROUND

The types and severity of clefts as well as palatal development and growth in children with repaired cleft lip and palate deformities can vary greatly. Independent of the technique used surgery produces scar tissue, which restricts palatal growth so that by the second decade many patients have an underdeveloped maxilla. Experience has shown that the maxillary retrognathism found in many cleft patients is not amenable to nonsurgical correction. Few long-term studies have evaluated the procedures, sequencing and timing of the treatment methods found to give the best results. This lack of reliable information means there is a serious gap in our ability to assess the value of different treatment modalities.

AIMS AND METHODS

From the viewpoint of orthodontics, this article describes the treatment protocol used by the cleft lip and palate team at the University Hospitals of the KU Leuven. The present treatment protocol is illustrated and questioned by two cases. The roles of prediction of facial growth and distraction osteogenesis are discussed.

Three-dimensional nasal changes following nasoalveolar molding in patients with unilateral cleft lip and palate: geometric morphometrics

OBJECTIVE

To evaluate three-dimensional changes in nasal morphology in patients with unilateral cleft lip and palate treated with presurgical nasoalveolar molding (NAM) to correct naso-labio-alveolar deformity.

DESIGN

This was a prospective, longitudinal study. Digital stereophotogrammetry was used to capture three-dimensional facial images, and x, y, and z coordinates of 28 nasal landmarks were digitized.

SAMPLE

Ten patients with unilateral cleft lip and palate.

MAIN OUTCOME MEASURES

Nasal form changes between T1 (age: 28 +/- 2 days, pre-NAM) and T2 (age: 140 +/- 2 days, post-NAM), using conventional measurements and finite-element scaling analysis.

RESULTS

Overall nasal changes were statistically different (p < .01), but no linear or curvilinear changes were found. Specifically, relative size increases were found on the noncleft side, involving the upper nose (30%), alar depth (20%), alar dome (30%), columella height (30%), and lateral wall of the nostril (17%). On the cleft side, the following showed a size increase: upper nose (8%), alar dome (5%), columella height (30%), and lateral wall of the nostril (30%). The cleft-side alar curvature, however, showed a large decrease in size (80%), but no changes on the noncleft side were found. Corresponding shape changes and angular changes were also found.

CONCLUSIONS

Using NAM, bilateral nasal symmetry in patients with unilateral cleft lip and palate was improved before surgical repair. Furthermore, slight overcorrection of the alar dome on the cleft side using pressure exerted by the nasal stent is indicated to maintain the NAM result.

Clinical study on eruption of permanent canines after secondary alveolar bone grafting

OBJECTIVE

Eruption of cleft-associated permanent canines was studied in 190 patients with unilateral cleft lip/palate and whose permanent canines had not erupted at the time of alveolar bone grafting. In 162 of these patients, width of bone defect was compared between patients who underwent surgical exposure of canines and those whose canines erupted naturally.

RESULTS

Cleft-associated canines naturally erupted after bone grafting in 150 patients (78.9%) and required surgical exposure in 36 patients (18.9%). Cleft-associated canines had not yet erupted in two patients. Two patients were lost to follow-up. Nasal-side bone defects were significantly wider in patients who underwent surgical exposure of cleft-associated permanent canines than in those whose cleft-associated permanent canines erupted naturally.

CONCLUSIONS

The present results suggest that nasal-side cleft width is related to the need for surgical exposure of permanent canines in children with cleft lip/palate.

[Post-orthodontic rehabilitation of the sequellae of alveolar clefts: implantation or periodontal plastic surgery?]

Just as they do for many cranio-facial deformities, the treatment team begins the care of cleft palate patients early and continues treatment over a long period. Throughout the growth period, they perform well-timed interventions and re-evaluations according to the individual plan they have prepared. When growth is completed and the orthopedic and orthodontic corrections have contributed as much as possible to an esthetic and functional equilibrium, a final prosthetic replacement will frequently be required. When the correct edentulous space between the teeth on each side of the defect has been created, or maintained, practitioners can choose between two alternatives: implants or traditional fixed bridges. They should analyze any secondary anatomic discrepancies, severe or superficial, that may have developed, and prepare the best therapeutic pathway for a reconstruction of crestal gingival morphology by means of periodontal surgery.