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

Comparison of Bone Formation After Early and Late Secondary Alveolar Bone Grafting in Patients With Unilateral and Bilateral Cleft Lip and Palate

OBJECTIVES

Late-stage secondary alveolar bone grafting (SBG) has a poor prognosis; however, the case selection and timing of orthodontic treatment have not been thoroughly investigated. This study aimed to clarify the prognosis of early-SBG and late-SBG in patients with unilateral or bilateral cleft lip and palate.

MATERIALS AND METHODS

Fifty-six patients underwent early-SBG performed before the eruption of the cleft-adjacent lateral incisors or canines (early-SBG group). Ten patients underwent late-SBG requiring significant tooth movement for gap closure; SBG was performed before phase II treatment for treatment efficiency, and tooth movement began approximately 3 months post-SBG (late-SBG group). Pre-SBG cleft width was measured; bone-bridge formation using the Chelsea scale and cleft gap closure post-SBG were evaluated. Types A and C bone bridges were considered adequate. These items were statistically compared between groups.

RESULTS

Cleft width in the early-SBG group was significantly smaller than that in the late-SBG group (p < 0.001). There were no significant differences in the percentage of adequate bone-bridge formation (p = 0.055) and cleft-gap closure (p = 1.000) between groups. However, the ratio of type A bone bridges was significantly higher in the early-SBG group than in the late-SBG group (p = 0.035).

CONCLUSION

These results suggest that, even in late-SBG, early orthodontic tooth movement to the graft bone leads to the formation of an adequate bone bridge, similar to early-SBG. However, the maintenance of cervical grafted bone after late-SBG may be less than that after early-SBG.

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

OBJECTIVE

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

DESIGN

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

SETTING

Craniofacial team in Florida.

PATIENTS/PARTICIPANTS

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

MAIN OUTCOME MEASURES

Barrier to orthodontic care and age of ABG.

RESULTS

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

CONCLUSIONS

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

Gingivoperiosteoplasty in Children with Cleft Lip and Palate: The Need for Alveolar Bone Grafting

OBJECTIVE

This study aimed to determine the efficacy of gingivoperiosteoplasty (GPP) in preventing alveolar bone grafting (ABG) among children with cleft lip and palate (CLP).

DESIGN/SETTING

Retrospective university hospital single center study.

PATIENTS

Children with CLP treated with GPP from 2000-2015 were included. Those under eight years of age, without definitive conclusions regarding need for ABG or with incomplete data were excluded.

INTERVENTIONS

Included patients were analyzed for demographics, cleft type, age at GPP, associated cleft surgery, use of nasoalveolar molding (NAM), indication for ABG, operating surgeon and presence of residual alveolar fistula. T-tests and Fisher's exact tests were utilized for statistical analysis.

MAIN OUTCOME MEASURE

The need for ABG.

RESULTS

Of the 1682 children identified with CLP, 64 underwent GPP and met inclusion criteria. 78% of patients with CLP who underwent GPP were recommended for ABG. Those who received GPP at a younger age (P = .004) and at the time of initial cleft lip repair (P = .022) were less likely to be recommended for ABG. Patients with complete CLP were more likely to be recommended for ABG than patients with cleft lip and alveolus only (P = .015). The operating surgeon impacted the likelihood of ABG (P = .004). Patient gender, race, ethnicity, laterality, and NAM were not significantly associated with recommendation for ABG.

CONCLUSION

GPP does not preclude the need for ABG. Therefore, the success of ABG after GPP and maxillary growth restriction should be analyzed further to determine if GPP is a worthwhile adjunct to ABG in cleft care.

What is the Effectiveness of Premaxilla Surgical Repositioning and its Stabilization Methods in Mixed Dentition Patients With Bilateral Cleft Lip and Palate?

OBJECTIVE

Verify the effectiveness of surgical repositioning of the premaxilla and its stabilization methods in patients with bilateral cleft lip and palate during mixed dentition.

DESIGN

Systematic review.

MATERIAL AND METHODS

The search was conducted in 7 databases (eg, Medline via PubMed; Scopus; Central Cochrane; LILACS; Embase, Web of Science; and Sigle via OpenGrey until August 2021), using the descriptors "premaxilla", "cleft Palate", and "bone transplantation".

INCLUSION CRITERIA

Clinical trials and observational studies that have patients with bilateral cleft who had a need for superior/posterior repositioning of the premaxilla on mixed dentition; Studies in any language was evaluted whitout time restriction of publication.

RESULTS

From 5572 records, 6 studies were included in the review with a total sample of 212 patients. Regarding the type of stabilization used in the premaxilla, the hybrid method (rigid and complementary semi-rigid stabilization) predominated, being observed in 184 patients (86.8%). A total of 17 failures were identified related to the surgical repositioning of the premaxilla, corresponding to 8% of the total number of surgeries. A meta-analysis of prevalence was performed, only with the retrospective studies. It was observed that the effectiveness rate of premaxilla repositioning was 92%, with a CI between 0.04 and 0.13, with all included studies showing a similar failure rate (0.08-0.09). The included studies also showed great homogeneity in this analysis (I2 = 0%; P = .75).

CONCLUSION

Although there are several alternatives and techniques for repositioning and stabilizing the premaxilla, the statistical result did not differ between the different techniques.

Racial Disparities in the Timing of Alveolar Bone Grafting

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

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

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

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

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

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

Extensive Gingivoperiosteoplasty Versus Secondary Alveolar Bone Grafting in Patients With Complete Bilateral Cleft Lip and Palate During the Mixed Dentition Period: A Retrospective Outcome Analysis

BACKGROUND

The concept of gingivoperiosteoplasty (GPP) in the mixed dentition stage as compared with secondary alveolar bone grafting (ABG) in management of alveolar cleft has not been much discussed upon. The authors present the experience with extensive GPP and ABG in the mixed dentition stage in complete bilateral alveolar cleft cases.

METHODS

A retrospective review of nonsyndromic patients with complete bilateral alveolar cleft operated on with either GPP or ABG (iliac crest) in the mixed dentition stage with at least 1-year follow-up was performed. Dental occlusal radiographs were evaluated for level of bone gain using Bergland and Witherow scales. Statistical evaluation of clinical success and procedure-related complications was conducted using χ2 test and odds ratio.

RESULTS

Twenty-four patients in the GPP group and 20 in the ABG group were comparatively studied. Clinical success rate as indicated by Bergland scales I and II (87.5% in GPP vs 82.5% in ABG; P = 0.731), complication rate (20.83% in GPP vs 30% in ABG; P = 0.484), and status of canine eruption showed no significant differences in clinical outcomes in both groups.

CONCLUSIONS

The technique of extensive GPP as described by authors shows equal efficacy to secondary ABG for management of bilateral alveolar clefts during the mixed dentition period.

Relapse-related factors of Le Fort I osteotomy in cleft lip and palate patients: A systematic review and meta-analysis

A systematic review search was based on the PICOS approach, as follows: population: cleft lip and palate patients; intervention: Le Fort I osteotomy; comparator: different surgical protocols; outcome: stability, recurrence or surgical complications; study designs: only case reports were excluded from the review. No restrictions were placed on language or year of publication. Risk of bias was analyzed, heterogeneity was assessed, and subgroup analysis was performed using a level of significance of 1% (p = 0.01). The search identified 248 citations, from which 29 studies were selected and a total of 797 patients enrolled. The level of agreement between the authors was considered excellent (k = 0.810 for study selection and k = 0.941 for study eligibility). Our results reported a mean maxillary advancement of 5.69 mm, a mean vertical downward/upward of 2.85/-2.02 mm and a mean clockwise rotation of 4.15°. Greater surgical relapse rates were reported for vertical downward movement (-1.13 mm, 39.6%), followed by clockwise rotation (-1.41°, 33.9%), sagittal (-0.99 mm, 17.4%) and vertical upward (0.11 mm, 5.4%) movements. No relevance was found regarding the type of cleft, the type of Le Fort I osteotomy, concomitant bone grafting, surgical overcorrection, postoperative rigid or elastic intermaxillary fixation, or retention splint. Study limitations were heterogeneity and the low number of high-quality studies. In spite of reported high relapse rates, Le Fort I osteotomy for maxillary reposition is the first-choice procedure for selected cleft lip and palate patients in whom extensive maxillary movements are not required, because of its safety and its three-dimensional movement versatility in one-step surgery. Otherwise, distraction osteogenesis should be considered as the gold standard treatment.

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

OBJECTIVE

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

DESIGN

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

SETTING

Single tertiary care institution.

PATIENTS

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

MAIN OUTCOME MEASURES

The number of RED candidates and treated patients.

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Endoscope-Assisted Multilayered Repair in Oronasal Fistula

Oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37% and remains a challenging problem for surgeons. Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity. Therefore, we report a multilayered technique for oronasal fistula closure using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap. This will increase the success rate after closure of small-sized oronasal fistula surgery without complications or recurrence (IRB: 2020-1671-0001).

Retrospective analysis of clinical outcomes in bilateral cleft lip and palate patients after secondary alveolar bone grafting and premaxilla osteotomy, using a new dento-maxillary scoring system

Evaluation of relevant clinical outcomes in patients with bilateral cleft lip and palate (BCLP) after secondary aveolar bone grafting (SABG) and premaxilla osteotomy (PMO), through the use of a new scoring system. Data were collected retrospectively from all patients with BCLP who were operated on between 2004 and 2014, at the end of follow-up. The treatment protocol consisted of SABG + PMO in patients aged between 9 and 13 years. At the end of follow-up, the following parameters were scored: (un)interrupted dental arch, skeletal sagittal relationship, bone height using the Bergland/Abyholm criteria, and the presence of postoperative fistula. These parameters were combined to produce a dento-maxillary scoring system, giving a final score between 1 and 10. For statistical analysis, the independent t-test was used. Of 55 children, 45 were suitable for analysis. The mean age at time of surgery was 12.0 years (8.9-16.4 yrs), and the mean follow-up time was 11.7 years (5.8-15.8 yrs). The average number of surgeries executed under general anesthesia was 6 (range: 3-11). The average dento-maxillary score in this patient cohort was 7.6 (1-10; median: 8). Among these patients, 31 had an uninterrupted dental arch; the average Bergland/Abyholm score was 2.07; 30 patients exhibited an Angle class I incisor relationship; and, in 38 cases, the oronasal communication was closed after SABG + PMO treatment. A significant effect of fistulas was seen on dento-maxillary score (p = 0.001). Specifically, a significant effect of fistulas was seen on interrupted dental arch (p = 0.002) and on Bergland/Abyholm score (p = 0.037). The proposed dento-maxillary scoring system is a straightforward tool that can be used to describe and analyze the amount of dento-maxillary rehabilitation at the end of the treatment. Persistence of oronasal fistulas in patients with BCLP has a significant impact on interruption of the dental arch, and can influence dental results at the end of the second decade.

A novel method for alveolar bone grafting assessment in cleft lip and palate patients: cone-beam computed tomography evaluation

Objectives

This retrospective cross-sectional study aimed to present a new method for secondary alveolar bone grafting (SABG) assessment and to qualitatively evaluate the SABG results in unilateral cleft lip and palate patients.

Materials and methods

Research was conducted according to the STROBE guidelines. The study group consisted of 21 patients with a mean age of 16 years. High-resolution cone-beam computed tomography (CBCT) was performed at least 1 year after grafting. The experimental side was the cleft side, and the contralateral side without a congenital cleft was the control. Measurements were performed at four levels of the maxillary central incisors’ roots according to the new scale with scores from 0 to 3. The sum of the scores provided a general assessment of bone architecture. The Wilcoxon signed-rank test was used for intergroup comparisons, and a Kappa coefficient was used for reproducibility measurements.

Results

High individual variability was found, and the bone architecture was significantly worse on the cleft side than on the noncleft side. The results showed 28.57% failure, 33.33% poor, 19.05% moderate, and 19.05% good results from the surgical procedure. Kappa coefficients produced results from 0.92 to 1.00 for intra-rater and from 0.81 to 1.00 for inter-rater reproducibility.

Conclusions

CBCT provides detailed information about alveolar bone morphology. The new assessment method is useful at every treatment stage and provides excellent repeatability. SABG did not provide good bone morphology, in most cases.

Clinical relevance

This research presents a new universal alternative for the assessment of SABG by utilizing CBCT.

Electronic supplementary material

The online version of this article (10.1007/s00784-020-03505-z) contains supplementary material, which is available to authorized users.