Predictors of complication for alveolar cleft bone graft

A systematic review of wide alveolar cleft repair techniques

Wide alveolar clefts impair secondary alveolar bone grafting due to deficient mucoperiosteal tissue for grafted bone coverage. Consequently, preparatory or alternative techniques are often required for closure of such defects. We conducted a PRISMA-adherent systematic literature review on wide alveolar cleft repair to compare treatment efficacies and patient populations. With this information, we provide guidance on the relative advantages and disadvantages of each examined method. Forty-two studies published from 1987-2022 were included, containing 332 patients treated with distraction osteogenesis (52.1%), orthognathic surgery (33.1%), local flap (8.1%), or free flap (6.6%) repair. There were no significant differences in patient ages between distraction osteogenesis device types (p = 0.401, Kruskal-Wallis) or treatment intervals, except that tooth-borne consolidation was significantly faster than bone-borne consolidation (p < 0.01, one-way analysis of variance [ANOVA] with Tukey honestly significant difference test). Orthognathic surgery and free flap patients were more likely to have prior failed cleft reconstructions than those who underwent distraction osteogenesis or local flap repair (p < 0.05, chi-square test of independence), suggesting a "second-line" designation to orthognathic surgery and free flap repair. Orthognathic surgery also had significantly higher osseous closure rates than other treatments (p < 0.0125, chi-square test with Bonferroni correction). Younger patients more often received orthognathic surgery or distraction osteogenesis whereas older patients received free or local flaps (p < 0.05, Welch's one-directional ANOVA with Games-Howell test). Each of the techniques evaluated have unique features regarding patient age, recovery duration/complexity preferences, and treatment history. Although the ideal treatment may differ between patients, orthognathic surgery and free flaps appear to be the most effective techniques for wide alveolar cleft repair.

The Effect of Vitamin D Level on The Prediction of The Success of Secondary Alveolar Cleft Grafting: A Retrospective Study

INTRODUCTION

Alveolar cleft grafting plays a vital role in the treatment of individuals with cleft lip and palate. Vitamin D plays a crucial role in bone healing.

METHODOLOGY

The study involved 40 patients with cleft alveolus who were seeking alveolar cleft grafting (ACG). Participants were categorized into 2 groups-study and control-based on their vitamin D levels: those with levels below 20 were placed in the control group, while those with levels above 20 were assigned to the study group.

RESULTS

Assessment of alveolar cleft grafting success rate was done by Bergland Scale assessment. The assessment using χ2 showed that the bone level in the study group was better than the control. However, the improvement was not statistically significant (P=0.2). Assessment of volumetric bone fill was done on the CBCT. The results were statistically checked by independent t-test and showed that the bone fill in the study group (224±78.4 mm3) was better than the control (176±135 mm3). However, the improvement was not statistically significant (P=0.17). Assessment of the incidence of fistula recurrence was done using the χ2 test. In the study group, the incidence of fistula was 5%, while in the control group, it was 30%. The incidence of success in reducing fistula recurrence was statistically significant (P=0.04).

CONCLUSION

Adjustment of vitamin D level may be a successful tool in predicting the success of the alveolar cleft grafting procedure, especially regarding the elimination of fistula recurrence.

Analysis of the Complications of Mandibular Cortical Bone with/without Particulate Artificial Bone Graft for Alveolar Cleft Reconstruction: A Retrospective Study

OBJECTIVES

To investigate postoperative complications in patients who underwent alveolar bone graft surgery using mandibular cortical bone (MCB) with/without particulate artificial bone (PAB).

DESIGN

Retrospective study.

SETTING

Department of Oral and Cranio-Maxillofacial Surgery in the hospital from August 2020 to August 2023.

PATIENTS

Patients who underwent alveolar bone graft using MCB were reviewed. They were diagnosed with unilateral or bilateral alveolar cleft, and some of them developed postoperative complications after MCB with/without PAB repair surgery.

INTERVENTIONS

No interventions.

MAIN OUTCOME MEASURE(S)

Complications.

RESULTS

Complications occurred in 12 of 149 patients who underwent surgery (8.05%). Among these evaluated patients, 10 had surgical site infection, 8 had mucosal dehiscence, 2 had discharge of resorbable plate debris, and 6 had grafted bone necrosis. Patients with bilateral alveolar clefts were more likely to experience complications (P = 0.033).

CONCLUSION

MCB with/without PAB grafting is effective enough for patients to undergo reconstruction of the alveolar process.

Effectiveness of maxillary cortical bone graft chips harvested by bone scraper, covered with platelet-rich fibrin (PRF), in reconstruction of alveolar clefts: comparative study

PURPOSE

The aim of this study is to assess the effectiveness of maxillary cortical bone graft chips harvested by bone scraper, covered with platelet-rich fibrin (PRF) in alveolar clefts.

PATIENTS AND METHODS

Seventy-two cleft patients were examined for their eligibility to be part in this comparative study; they were randomly divided into group A, thirty-six patients had received cancellous bone chips from iliac crest; group B, thirty-six had received cortical bone chips harvested from maxilla using a curved bone scraper, covered with PRF. The clinical success over the follow-up period was evaluated on the basis of elimination of the oronasal fistula, radiographic assessment of bone graft volume, achievement of the osseous continuity of the alveolar arch, and the extent of the vertical bone height.

RESULTS

The mean of volume gained in group A was 0.8053 ± 0.9682, while for group B was 0.7397 ± 0.7703. The amount of vertical bone loss between groups was registered, and the chi-square test revealed insignificant differences between study groups (p = 0.547). The result of the frequency of fistula development after grafting in both groups was insignificant (p = 0.074). Also, for the continuity of the maxilla as a one piece, the results were insignificant differences between study groups (p = 0.058).

CONCLUSION

In conclusion of our study, intraoral harvesting of maxillary cortical chips by bone scraper covered with PRF is able to achieve a valid functional and aesthetic support in alveolar cleft patients, meeting the reconstructive goals.

Bioglass 45S5, a relevant alternative to autogenous harvesting for secondary alveolar bone grafts in clefts? Retrospective study of one hundred surgeries

The secondary alveolar bone grafting (SABG) step restores the continuity of the alveolar bone necessary for dentition. Faced with the complications of autografts, synthetic biomaterials such as Bioglass (BG) 45S5 have been proposed. The objective was to evaluate the success rate of SABG with the addition of BG 45S5 and to highlight the prognostic factors. Patients who underwent operation between 2015 and 2021 and had follow-up cone-beam computed tomography (CBCT) were analyzed. Multivariate analysis was performed to determine factors influencing radiographic success. A total of 102 SABG were analyzed. They were unilateral total cleft lip and palate (49, 48.0%). The mean age at surgery was 9.32 ± 3.09 years. Surgeries were performed mainly outside a syndromic context and without a family history after orthodontic preparation. The radiographic success rate at 1 year was 80.4%. Mixed dentition stage (odds ratio [OR] = 7.3, p = 0.024), absence of syndromic context (OR = 20.7, p = 0.024) and female sex (OR = 4.88, p = 0.021) were factors predictive of surgical success. The use of BG 45S5 instead of autograft is relevant for SABG, with a 1-year success rate of over 80%. The stage of mixed dentition, the absence of syndromic context, and female sex were factors for good prognosis.

Influence of osseous structure characteristics of unilateral alveolar cleft on outcomes of alveolar bone grafting: a retrospective study

BACKGROUND

To enhance the success rate of alveolar bone grafting, it is crucial to identify the factors that may influence the postoperative bone formation. This study aimed to investigate the impact of various osseous structure characteristics of alveolar clefts on the survival ratio of autogenous cancellous bone particle grafts.

METHODS

A retrospective study was conducted on 60 patients who underwent surgery performed by the same surgeon between 2016 and 2022. Two researchers measured and recorded the bone defect volume (DV), postoperative bone formation volume at 1 year, contact area between the graft and the bone surface within the cleft (S), cleft width (CW), osseous occlusion relationships, and presence of a cleft palate and initial bone bridge within the cleft for each patient. Pearson correlation analysis, Spearman's correlation analysis, and multiple linear regression analysis were performed.

RESULTS

The analysis results revealed statistical correlations between DV, CW, ratio of S to DV, cleft palate, initial bone bridge presence, and occlusion relationships with the survival rate. Multiple linear regression analysis showed that initial bone bridge and occlusion relationships affected the graft survival rate.

CONCLUSIONS

Based on the presence of initial bone bridges and occlusions, we can make a rough estimate of the postoperative bone formation outcome in patients. However, the underlying mechanisms by which these two factors influence the bone formation require further investigation. In addition, preoperative orthodontic treatment to improve occlusal relationships may improve the postoperative bone formation outcomes in alveolar bone grafting.

Bone Tissue Engineering Strategies for Alveolar Cleft: Review of Preclinical Results and Guidelines for Future Studies

The current standard of care for an alveolar cleft defect is an autogenous bone graft, typically from the iliac crest. Given the limitations of alveolar bone graft surgery, such as limited supply, donor site morbidity, graft failure, and need for secondary surgery, there has been growing interest in regenerative medicine strategies to supplement and replace traditional alveolar bone grafts. Though there have been preliminary clinical studies investigating bone tissue engineering methods in human subjects, lack of consistent results as well as limitations in study design make it difficult to determine the efficacy of these interventions. As the field of bone tissue engineering is rapidly advancing, reconstructive surgeons should be aware of the preclinical studies informing these regenerative strategies. We review preclinical studies investigating bone tissue engineering strategies in large animal maxillary or mandibular defects and provide an overview of scaffolds, stem cells, and osteogenic agents applicable to tissue engineering of the alveolar cleft. An electronic search conducted in the PubMed database up to December 2021 resulted in 35 studies for inclusion in our review. Most studies showed increased bone growth with a tissue engineering construct compared to negative control. However, heterogeneity in the length of follow up, method of bone growth analysis, and inconsistent use of positive control groups make comparisons across studies difficult. Future studies should incorporate a pediatric study model specific to alveolar cleft with long-term follow up to fully characterize volumetric defect filling, cellular ingrowth, bone strength, tooth movement, and implant support.

Postoperative evaluation of bone bridge after alveolar bone graft with cortical bone lining technique

OBJECTIVE

For alveolar bone grafting (ABG), we have been performing surgery using a technique in which a cortical bone lining iliac endplate is applied to the anterior nasal aperture inferior margin. Herein, we used conventional and cortical bone lining techniques to examine the postoperative bone-bridge morphology after ABG.

STUDY DESIGN

Fifty-five unilateral patients who underwent ABG at our clinic from October 2012 to March 2019 were included. We used postoperative CT data to compare the labiolingual width of the grafted bone and anterior-posterior and vertical shapes of the nasal aperture inferior margin with respect to the ungrafted side.

RESULTS

The cortical bone lining technique was superior to the conventional method. The cortical bone lining technique showed good results regardless of alveolar cleft width or oral-nasal fistula. Also, tooth movement into the grafted area was involved in maintaining the residual graft bone; however, the cortical bone lining technique had better results.

CONCLUSIONS

The cortical bone lining technique allows for the physical closure of nasolateral mucosal fistulas when it is technically difficult, and it can apply sufficient pressure to the bone marrow cancellous bone filling over the cortical plate bone. Our results illustrate the effectiveness of the cortical bone lining technique.

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 Alveolar Bone Grafting Is Associated with Lower Regraft Rates and Improvements in Long-Term Psychosocial Outcomes

BACKGROUND

Late childhood (8 to 10 years of age) has emerged as a vulnerable period in children with cleft and craniofacial anomalies such that increased interventions during this period are associated with worse long-term patient-reported anxiety and depressive symptoms. These findings suggest that one possible practice change may be to consider changes in timing for surgical treatment algorithms. In this work, the authors investigated outcomes in altering the timing of the most common operation in late childhood for cleft lip and palate patients, alveolar bone grafting.

METHODS

A two-part, multi-institutional cohort study was conducted. To understand the feasibility of changing alveolar bone graft timing with respect to surgical success, reoperation rates were retrospectively compared among patients grafted at different ages (4 to 7, 8 to 10, and 11 to 13 years of age). To understand the long-term effect of changing alveolar bone graft timing on psychosocial outcomes, the psychosocial suite of the Patient-Reported Outcomes Measurement Information System was prospectively administered to teenagers and adults with cleft lip and palate.

RESULTS

Among the three age groups, early grafting (4 to 7 years of age) demonstrated the lowest regraft rates compared with the other groups. As these results suggested that early grafting is a viable alternative to standard timing, we next compared the differences in long-term psychosocial outcomes. Patients who were grafted early reported lower levels of anxiety and depressive symptoms as teenagers and adults.

CONCLUSION

Altering timing of one stage in cleft lip and palate reconstruction to an earlier age decreases regraft rates and improves long-term patient-reported anxiety and depressive symptoms.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Protocol and Evaluation of 3D-Planned Microsurgical and Dental Implant Reconstruction of Maxillary Cleft Critical Size Defects in Adolescents and Young Adults

Functional and esthetic final reconstruction of the cleft maxilla is still challenging. Current reconstructive and augmentation techniques do not provide sufficient bone and soft tissue support for the predictable rehabilitation with dental implants due to presence of maxillary bone critical size defects and soft tissue deficiency, scaring and poor vascularity. In this article the protocol for the use of 3D virtual surgical planning and microvascular tissue transfers for the reconstruction and rehabilitation of cleft maxilla is presented. Twenty-five patients (8 male/17 female) aged 14–41 years old with cleft-associated critical size defects were treated by 3D-virtual planned microvascular tissue transfers taken either from fibula, iliac crest, radial forearm, or medial femoral condyle. Follow-up lasted 1–5 years. No significant bone resorption (p > 0.005) nor volume loss of the graft was observed (p = 0.645). Patients received final permanent prosthetic reconstruction of the anterior maxilla based on 2–5 dental implants, depending on the defect severity. This is the first study presenting the use of virtual planning in the final restoration of the cleft maxilla with microvascular tissue transfers and dental implants. Presented protocol provide highly functional and aesthetic results.

Efficacy of Laser Therapy in Reducing Swelling and Pain Following Alveolar Bone Grafting: A Randomized Controlled Trial

PURPOSE

This randomized controlled trial aimed to explore the efficacy of laser therapy in reducing swelling and pain in female patients after alveolar bone grafting in the hope of providing a new method for the treatment of patients with swelling after alveolar bone grafting.

PATIENTS AND METHODS

From August 2019 to June 2020, 82 female patients with soft tissue swelling after alveolar bone grafting in our hospital were enrolled in this prospective blinded randomized controlled trial. The patients were randomized divided into the study group (receiving laser therapy) and the control group (receiving routine postoperative intervention). Swelling and pain were evaluated at postoperative day (POD) 1, 3, and 5, and the quality-of-life at POD 1 and 5. The healing success rate and postoperative satisfaction were evaluated at 3 months postoperatively.

RESULTS

The pain severity in the study group was lower than that in the control group at POD 3 and 5 (P<.05). The study group had significantly higher scores of general health, vitality, bodily pain, social functioning, physical functioning, role-physical, role-emotional, and mental health than the control group at POD 5 (P<.05). In addition, the scores of general health, vitality, bodily pain, social functioning, physical functioning, role-physical, role-emotional, and mental health of the 2 groups were higher at POD 5 versus POD 1 (P<.05). The study group had a significantly higher healing success rate and postoperative satisfaction rate than the control group at 3 months postoperatively (P<.05).

CONCLUSIONS

Laser therapy can effectively reduce swelling and pain and improve the quality-of-life of female patients after alveolar bone grafting.

Biomechanical behavior of an alveolar graft under maxillary therapies

Cleft lip and palate is a congenital defect that affects the oral cavity. Depending on its severity, alveolar graft surgery and maxillary orthopedic therapies must be carried out as a part of the treatment. It is widely accepted that the therapies should be performed before grafting. Nevertheless, some authors have suggested that mechanical stimuli such as those from the maxillary therapies could improve the success rate of the graft. The aim of this study is to computationally determine the effect of maxillary therapies loads on the biomechanical response of an alveolar graft with different degrees of ossification. We also explore how the transverse width of the cleft affects the graft behavior and compare results with a non-cleft skull. Results suggest that stresses increase within the graft as it ossifies and are greater if maxillary expansion therapy is applied. This has consequences in the bone remodeling processes that are necessary for the graft osseointegration. Maxillary orthopedic therapies after graft surgery could be considered as a part of the treatment since they seem to act as a positive extra stimulus that can benefit the graft.

Mind the Gap: Alveolar Bone Graft Revision in the Era of Computed Tomography

OBJECTIVE

To determine the rate of revision alveolar bone grafting (ABG) in patients with cleft lip and palate (CLP) before and after the introduction of postoperative computed tomography (CT).

DESIGN

Retrospective case-control study analyzing the incidence of revision ABG in patients with and without postoperative CT scans for graft success evaluation.

SETTING

Academic tertiary care pediatric hospital.

PATIENTS

Eighty-seven patients with CLP or cleft lip and alveolus treated with autologous iliac crest bone grafting for alveolar clefts over a 10-year period (January 2009 to March 2019) with minimum 6-month follow-up. Fifty patients had postoperative CT evaluation; 37 did not.

INTERVENTIONS

Postoperative CT to determine ABG success, versus standard clinical examination and 2-dimensional radiographs.

MAIN OUTCOME MEASURES

Requirement for revision ABG, defined as failure of the original graft by clinical or radiographic examination.

RESULTS

Fifty-eight percent of patients underwent a postoperative CT scan at median interval of 10 months after surgery. Patients with postoperative CT evaluation had a 44% rate of revision ABG (22/50) for inadequate graft take, compared to 5% (2/37) in patients without postoperative CT (P < .001; 95% CT, 31%-58% in the CT group, 1%-16% in the non-CT group).

CONCLUSIONS

Computed tomography evaluation after ABG is associated with a significantly increased revision rate for inadequate graft take. The presence of a secondary palatal fistula at the time of original ABG is not associated with revision requirement. Lack of standardized dental and orthodontic records complicates the study of ABG outcomes and presents an area for systems-based improvement.

Bone Grafting of Alveolar Clefts

The goals of alveolar cleft repair include (1) stabilization of the maxilla, (2) permitting tooth eruption, (3) eliminating the oronasal fistula, (4) improving aesthetics, and (5) improving speech. Alveolar cleft repair should be considered one of the steps of a larger comprehensive orthodontic management plan. In conjunction with closure of the oronasal fistula, a variety of grafting materials can be used in the alveolar cleft. Autogenous grafts have been found to have greater efficacy compared with allogenic or xenogeneic bone, substitute bone, and alloplasts but with more donor site morbidity.

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).

Beta-tricalcium phosphate promotes osteogenic differentiation of bone marrow-derived mesenchymal stem cells through macrophages

Macrophages are vital regulators of skeletal remodeling and osseous repair. Beta-tricalcium phosphate (β-TCP) is a synthetic ceramic biomaterial that has shown promise as bone substitute. However, whether and how β-TCP affects osteogenesis-related responses of macrophages has rarely been studied. The aims of this study were to explore (a) the effects of β-TCP on osteogenic differentiation of bone marrow-derived mesenchymal stem cells (BMSCs) co-cultured with macrophages and (b) on macrophage polarization as well as macrophage gene and protein expression profiles. BMSC osteogenic differentiation capacity in vitro was enhanced in β-TCP-induced co-cultured BMSCs compared to that in BMSC monocultures. We also found that macrophages induced with 25 mg ml^-1 β-TCP extract had more significant immune responses and switched to the M2 phenotype. Expression levels of the Wnt signaling pathway modulators wingless-type MMTV integration site family, member 6 (WNT6) and Wnt inhibitory factor 1 (WIF1) were upregulated and downregulated, respectively, in macrophages treated with β-TCP extract. Our findings suggest that β-TCP enhances osteogenic differentiation of BMSCs by inducing macrophage polarization and by regulating the Wnt signaling pathway, thereby highlighting its therapeutic potential for bone healing through osteoimmunomodulatory properties.

The Postoperative Changes of Nasal Septum and Maxilla After Alveolar Bone Grafts in Patients With Unilateral Alveolar Cleft

BACKGROUND

Alveolar clefts give rise to many aesthetic and functional problems among affected patients. Therefore, surgical adjustments of the bony defective anomalies are important. The authors performed secondary bone grafts and analyzed the effects particularly on the nasal septum and maxillary area (midface).

METHODS

The patients who had alveolar bone grafts were retrospectively reviewed with pre/postoperative 3-dimensional computed tomography; the measurements included distances between the anterior nasal spine (ANS) and the vertical midline, angles between the nasal septum and the transverse line, and angles between the floor of the pyriform aperture and the transverse line.

RESULTS

A total number of 23 patients were finally included in the study. The mean age of the patients was 9.7 ± 1.95 years (range, 7-14 years). The mean distance between the ANS and the vertical midline was 5.3 ± 4.70 mm/4.9 ± 4.15 mm pre/postoperatively, showing the mean paired difference of 0.4 ± 0.89 mm (P < 0.05). The mean angles between the nasal septum and the transverse line and between the floor of the pyriform aperture and the transverse line were 64.5 ± 14.69°/65.9 ± 13.73° and 21.7 ± 8.94°/11.5 ± 7.03° pre/postoperatively, showing the mean paired differences of -1.4 ± 2.78° and 10.1 ± 8.20°, respectively (both P < 0.05).

CONCLUSION

The results suggest that secondary alveolar bone grafting has expanded effects on the adjacent midfacial structures.

Patients and informal caregivers’ questions about alveolar bone graft post-operative care

ABSTRACT Objectives: to identify patients’ and informal caregivers’ questions related to alveolar bone graft post-operative care. Methods: analytical and cross-sectional study, developed in a public and tertiary hospital between October 2017 and February 2018. The sample consisted of 46 participants. Data collection occurred during the preoperative nursing consultation through interview. The doubts were described in a form prepared by the researchers and later grouped by similarity of the subject. Results: doubts referred to diet (type of food, consistency, temperature and time period), surgical wound care (oral hygiene, graft rejection, removal of surgical points), post-operative complications (bleeding and edema), convalescence period (sun exposure, physical effort, time away from activities, length of stay) and medications. Conclusions: identifying the doubts allowed planning and implementing nursing care focused on the real needs of the clientele, favoring the rehabilitation process.

Extracellular Matrix Composition and Remodeling: Current Perspectives on Secondary Palate Formation, Cleft Lip/Palate, and Palatal Reconstruction

Craniofacial development comprises a complex process in humans in which failures or disturbances frequently lead to congenital anomalies. Cleft lip with/without palate (CL/P) is a common congenital anomaly that occurs due to variations in craniofacial development genes, and may occur as part of a syndrome, or more commonly in isolated forms (non-syndromic). The etiology of CL/P is multifactorial with genes, environmental factors, and their potential interactions contributing to the condition. Rehabilitation of CL/P patients requires a multidisciplinary team to perform the multiple surgical, dental, and psychological interventions required throughout the patient's life. Despite progress, lip/palatal reconstruction is still a major treatment challenge. Genetic mutations and polymorphisms in several genes, including extracellular matrix (ECM) genes, soluble factors, and enzymes responsible for ECM remodeling (e.g., metalloproteinases), have been suggested to play a role in the etiology of CL/P; hence, these may be considered likely targets for the development of new preventive and/or therapeutic strategies. In this context, investigations are being conducted on new therapeutic approaches based on tissue bioengineering, associating stem cells with biomaterials, signaling molecules, and innovative technologies. In this review, we discuss the role of genes involved in ECM composition and remodeling during secondary palate formation and pathogenesis and genetic etiology of CL/P. We also discuss potential therapeutic approaches using bioactive molecules and principles of tissue bioengineering for state-of-the-art CL/P repair and palatal reconstruction.

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

OBJECTIVE

To evaluate factors affecting incidence of complications after secondary alveolar bone grafting with premaxillary osteotomy (SABG + PO) in children with complete bilateral cleft of lip and palate (BCLP).

MATERIALS AND METHODS

Data were collected from children with BCLP treated with SABG + PO from 2004 to 2014 at our institute. Preoperative parameters included age, donor site, race, gingival health, bone quality around cleft-related teeth, premaxilla position, graft timing, presence of canines in the cleft, and presence of deciduous teeth around the cleft area. Logistic regression and the chi-squared test were used to assess correlations and the incidence of complications.

RESULTS

In the 64 patients, a significant correlation was found between complication rate and timing of bone grafting with respect to early versus late SABG + PO (p = 0.041), age > 12 years (p = 0.011; odds ratio (OR) 5.9; 95% confidence interval (CI) 1.49-23.93), malposition of the premaxilla (p = 0.042; OR 3.3; 95% CI 1.04-10.13), and preoperative bone quality around cleft-related teeth (p = 0.005; OR 5.3; 95% CI 1.6-17.2).

CONCLUSIONS

The timing of SABG + PO is essential, as early SABG + PO is associated with fewer complications. A malpositioned premaxilla and poor bone quality around cleft-related teeth are associated with more complications. Therefore, preoperative orthodontic repositioning of the malpositioned premaxilla before SABG + PO should be considered.

CLINICAL RELEVANCE

Analysis of treatment protocols and complications for BCLP patients underscores that proper timing of SABG + PO and correct premaxilla repositioning help reduce complications.

Soft tissue molding technique in cleft lip and palate patient using laser surgery in combination with orthodontic appliance: A case report

BACKGROUND

Although surgical treatment protocols for cleft lip and palate patients have been established, many patients still have some soft tissue defects after complete healing from surgical interventions. These are excess soft tissue, high attached fraena and firmed tethering scares. These soft tissue defects resulted shallowing of vestibule, restricted tooth movement, compromised periodontal health and trended to limit the maxillary growth. The aim of this case report was to present a method of correcting soft tissue defects after conventional surgery in cleft lip and palate patient by using combined laser surgery and orthodontic appliance.

CASE REPORT

A bilateral cleft lip and palate patient with a clinical problem of shallow upper anterior vestibule after alveolar bone graft received a vestibular extension by using CO₂ laser with ablation and vaporization techniques at 4 W and continuous wave. A customized orthodontic appliance, called a buccal shield, was placed immediately after surgery and retained for 1 month to 3 months until complete soft tissue healing. The procedures were performed 2 episodes. Both interventions used the same CO₂ laser procedure. The first treatment resulted in partial re-attachment of soft tissue at surgical area. The second laser operation with the proper design of buccal shield providing passive contact with more extended flange resulting in a favorable outcome from 1 year follow up. Then the corrective orthodontic treatment could be continued effectively.

CONCLUSION

The CO₂ laser surgery was a proper treatment for correcting soft tissue defects and the design of buccal shield was a key for success in molding surgical soft tissue.

Alveolar Bone Graft: Clinical Profile and Risk Factors for Complications in Oral Cleft Patients

OBJECTIVE

The aim of this study was to investigate clinical aspects and predisposing factors for alveolar bone graft complications in persons born with oral clefts.

DESIGN

A total of 105 patients, aged 7 to 57 years old, who received alveolar bone graft at the Cranio-maxillofacial Surgery Center in the National Institute of Traumatology and Orthopedics (INTO), Rio de Janeiro (RJ) from 2009 to 2014 were selected. Data were collected concerning the type of oral cleft, family history of cleft, medical and dental exam, donor area, type of graft material, repaired surgical treatment done, and postoperative follow-up examinations.

RESULTS

Postoperative complications developed in 31 patients (32.9%). The mean age at grafting was 16.79 years for the group without complications (n = 63) and 20.13 years for the group with postoperative complications (n = 31). There was a positive association between age and type of graft and cases with alveolar bone graft complications. Patients aged 12 years or more had a four times more chance of developing alveolar bone graft complications. Particulate bone graft from iliac crest demonstrated better results compared with block graft or mixed graft.

CONCLUSION

Patients with cleft lip and palate who were 12 years or older had a greater chance of developing complications after grafting the alveolar bone. Furthermore, particulate alveolar graft from iliac crest had significantly better outcomes.

Osteogenesis effect of guided bone regeneration combined with alveolar cleft grafting: assessment by cone beam computed tomography

Cone beam computed tomography (CBCT) allows for a significantly lower radiation dose than conventional computed tomography (CT) scans and provides accurate images of the alveolar cleft area. The osteogenic effect of guided bone regeneration (GBR) vs. conventional alveolar bone grafting alone for alveolar cleft defects was evaluated in this study. Sixty alveolar cleft patients were divided randomly into two groups. One group underwent GBR using acellular dermal matrix film combined with alveolar bone grafting using iliac crest bone grafts (GBR group), while the other group underwent alveolar bone grafting only (non-GBR group). CBCT images were obtained at 1 week and at 3 months following the procedure. Using Simplant 11.04 software, the bone resorption rate was calculated and compared between the two groups. The bone resorption rate from 1 week to 3 months following bone grafting without the GBR technique was 36.50±5.04%, whereas the bone resorption rate using the GBR technique was 31.69±5.50% (P=0.017). The application of autogenous iliac bone combined with the GBR technique for alveolar bone grafting of alveolar cleft patients can reduce bone resorption and result in better osteogenesis.

Comprehensive orthodontic treatment of adult patient with cleft lip and palate

The aim of the paper is to present full orthodontic treatment of an operated cleft lip adult patient. Case Report. An 18-year-old patient consulted for severe crowded teeth. He comes from a poor family. At that time he already had four operations (velum, palate, lip, and myringotomy). Treatment included maxillary expansion, tooth extraction, and fixed orthodontic, as well as kinesiology and speech therapy treatment. A multidisciplinary approach allowed us to achieve successfully an excellent result for this patient and gave him a harmonic smile and an optimal function without orthognathic surgery. Two years after treatment, occlusion remains stable.