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

A Survey on Alveolar Bone Grafting in Indian Cleft Centers

OBJECTIVE

To assess the factors influencing the type and timing of Alveolar Bone Grafting (ABG) among cleft centers throughout India. To examine the decision-making criteria for orthodontic treatment and the timing of ABG.

DESIGN

Cross sectional survey.

METHOD

This survey was based on a convenience-based sample selected from cleft teams across India. The survey was formulated using the SurveyMonkey platform and emailed to 40 cleft teams. The survey included questions on demographics, timing, surgical protocol, orthodontic protocol, radiograph prescription rate, assessment methods for the success of ABG and three scenarios for evaluating the timing of the bone graft. The Chi-squared test was performed to evaluate the difference in opinion between specialists. The inter-examiner reliability was assessed using Kappa statistics.

RESULTS

Thirty-five units completed the questionnaire. Most units operate with 1-2 surgeons, with 42.9% of them treating cleft patients for under 5 years. Only 11.4% of centres routinely advised oblique occlusal radiographs for post-surgery evaluation, and 31.4% prescribed CBCT. However, 40% of cleft teams did not perform audits to evaluate the success of ABG, and less than 50% advised radiographs six months post-surgery. Around 26% of centres do not routinely provide orthodontic treatment pre-ABG. The inter-examiner reliability for case scenarios showed poor agreement between the clinicians.

CONCLUSION

The survey showed a serious lack of consensus in the ABG treatment among cleft teams in India and emphasises the need for standardised protocols for the treatment of children with cleft palate. There is an urgent need to develop core outcome set in cleft.

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.

Timing of Alveolar Bone Graft and Barriers to Care

OBJECTIVE

The current standard timing for alveolar bone grafting (ABG) occurs during mixed dentition, typically between the ages of six and twelve. A delay in receiving this operation is associated with an increase in graft loss and an overall thinner maxilla. This study aims to determine whether socioeconomic barriers are associated with a delay in timely ABG.

DESIGN

A retrospective analysis of patients who received ABG at our institution since 2012. Patient demographics, cleft classifications, operative details, and surgical dates were examined. A logistic regression model was created using socioeconomic variables to predict patients receiving delayed ABG. Significant variables were then included in a backwards selection logistic regression, followed by a final analysis of maximum likelihood estimates.

SETTING

Single-institution, primary cleft care center.

PATIENTS

202 patients with cleft palates who underwent ABG.

INTERVENTIONS

ABG.

MAIN OUTCOME MEASURES

Timing in which patients received ABG: standard (6-12 years) and delayed (>12 years).

RESULTS

Female sex was a protective factor in the timing of ABG in our initial univariate analysis (OR = 0.44; p  =  .015). Socioeconomic factors resulting in delayed presentation for ABG include median income (OR = 1.0; p  =  .018) and public insurance status (OR = 3.75; p < .001). Median income, sex, and driving distance to the cleft clinic were not significant following backward elimination, however, private insurance status remained significant (OR = 3.71; p  =  .0001).

CONCLUSION

Patients with public insurance are approximately 3.75 times more likely to receive ABG during permanent dentition. Multidisciplinary teams should work closely with patients on public insurance to ensure timely delivery of ABG.Level of Evidence III, Retrospective.

Alveolar Bone Grafting in Unilateral Cleft Lip and Palate: Impact of Timing on Palatal Shape

Alveolar bone grafting (ABG) is a critical surgical intervention in patients with a cleft of the alveolus, aimed at reconstructing the alveolar ridge to facilitate proper eruption, periodontal support, and alignment of adjacent permanent teeth. The optimal timing for ABG remains debated, with late secondary ABG between the ages of 9 and 11 being widely adopted. This study compared the palatal shapes of 28 children at a mean age of 9.5 years (SD = 0.7) who underwent early secondary ABG at a mean age of 2.1 years (SD = 0.6) or 33 children at a mean age of 10.8 years (SD = 1.5) who underwent late secondary ABG at a mean age of 8.6 years (SD = 1.3) to 60 non-cleft controls at a mean age of 8.6 years (SD = 1.2). The palatal shapes were captured with 239 landmarks digitized on the palate on a digital model. Utilizing geometric morphometric methods, i.e., generalized Procrustes superimpositions, principal component analysis, and permutation tests, we assessed the impact of ABG timing on palatal morphology. The first five principal components (PCs) explained 64.1% of the total shape variability: PC1 = 26.1%; PC2 = 12%; PC3 = 11.9%; PC4 = 7.8%; and PC5 = 6.4%. The Procrustes distance between both cleft groups and the control group was more than twice as large as the Procrustes distance between the early ABG and late ABG groups. Nonetheless, all intergroup differences were statistically significant. Our findings suggest that early ABG has a limited negative effect on palatal shape, providing comparable outcomes to late ABG. The study highlights the potential suitability of early ABG, challenging conventional practices and encouraging further exploration into its long-term effects on maxillary growth.

Interdisciplinary Treatment of a Case With Unilateral Cleft Lip and Palate in the Mixed Dentition

A 10-year-old girl had reported to Sharad Pawar Dental College. Her parents had chief complaints of lip and palate deformity. On examination, it was found that the patient had unilateral cleft lip and palate on the right side. The aim was to expand the maxilla with alveolar bone grafting in the cleft region to facilitate the eruption of permanent canine and further reduce the deformity to prepare the patient for face mask therapy, reduce morbidity in the permanent dentition, and avoid Le Fort one surgery in the future. She had been previously operated on for cleft lip repair and palatal fistula closure eight years back. The present condition in the mixed dentition needed arch expansion, bone in the cleft region for the eruption of permanent canine, and further arch alignment for facemask therapy. This would reduce the severity of skeletal deformity and later on avoid the surgical advancement of the maxilla.