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Briss DS, Long RE, Peterman JB, Doucet JC, Daskalogiannakis J, Hathaway RR, Mercado AM, Russell K, Stauffer L. Evaluating SWAG and Its Validity When Compared to 3D Imagery of Secondarily Grafted Cleft Sites. Cleft Palate Craniofac J 2023:10556656231207570. [PMID: 37844606 DOI: 10.1177/10556656231207570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE To test validity of 2D Standardized Way to Assess Grafts (SWAG) ratings to assess 3D outcomes of bone grafting (ABG). PATIENTS 43 patients (34 UCLP, 9 BCLP) with non-syndromic complete clefts, bone-grafted at mean age 9yrs/3mos, with available post-graft occlusal radiographs and cone beam computed tomography (CBCT) (taken mean 4yrs/9mos post-ABG). MAIN OUTCOME MEASURES 2D occlusal radiographs rated twice using SWAG by 6 calibrated raters. 12 scores were averaged and converted to a percentage reflecting bone-fill. Weighted Kappas were assessed for SWAG reliability. 3D cleft-site bone volume was calculated by 1 rater using ITK-SNAP. 13 cleft sites were re-measured by the 'one rater' for 3D reliability using Intraclass Correlation Coefficient (ICC). 2D versus 3D ratings were compared using paired t-test, independent samples t-test, Bland-Altman and Linear Regression. Significance level was P = .5. RESULTS 2D reliability was 0.724 (intra-rater) and 0.546 (inter-rater). 3D reliability was 0.986. Bland-Altman plot comparing 2D vs 3D showed for 45 of 47 graft-sites were within 2 SD's. Mean % bone-fill was 64.11% with 2D and 69.06% with 3D (mean difference = 4.95%) that was a non-significant difference in both t-tests. Regression showed a statistically significant relation between the two methods (r2 = 0.46; P = .0001). CONCLUSION 2D SWAG systematically and non-significantly underestimated bone-fill. There was a significant correlation between 2D/3D methods. Bland-Altman analysis illustrated the similarity of the two methods. For comparisons of group (cleft treatment Centers') bone grafting outcomes, the 2D method may suffice as a proxy for the 3D method. However, with individual variation up to 40% in 2D estimates of actual 3D volume, 2D SWAG method cannot be used in place of 3D images.
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Affiliation(s)
- David S Briss
- Department of Orthodontics, Rutgers University School of Dental Medicine, Newark, NJ, USA
| | - Ross E Long
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
| | - John B Peterman
- Department of Orthodontics, Rutgers University School of Dental Medicine, Newark, NJ, USA
| | | | | | - Ron R Hathaway
- Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ana M Mercado
- Orthodontic Treatment Program, Nationwide Children's, Columbus, OH, USA
| | - Kathy Russell
- Faculty of Dentistry, Dalhousie University, Halifax, NS, Canada
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Long RE, Hathaway RR. Practice-based Evidence from Comparative Effectiveness Research to Inform Evidence-based Practice. Cleft Palate Craniofac J 2023:10556656231198661. [PMID: 37649309 DOI: 10.1177/10556656231198661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Affiliation(s)
- Ross E Long
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
| | - Ronald R Hathaway
- Orthodontics and Pediatric Dentistry, University of Michigan, Ann Arbor, MI, USA
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Gillgrass T. The orthodontic management of patients with cleft lip and palate: from birth to the late mixed dentition. Br Dent J 2023; 234:873-880. [PMID: 37349434 DOI: 10.1038/s41415-023-5955-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 06/24/2023]
Abstract
This is the first of two papers outlining the orthodontic management of patients with cleft lip and palate. This paper will review orthodontic input into children with cleft lip and palate from birth to the late mixed dentition before definitive orthodontics. It will emphasise the importance of timing in alveolar bone grafting, the role of the general dental practitioner and the impact of timing on definitive orthodontic outcome.
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Affiliation(s)
- Toby Gillgrass
- Cleft Surgical Service for Scotland & Glasgow Dental Hospital and School, Glasgow, United Kingdom.
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Gillgrass T. The orthodontic management of patients with cleft lip and palate: from the permanent dentition and the adult returning to the service. Br Dent J 2023; 234:892-898. [PMID: 37349437 DOI: 10.1038/s41415-023-5956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 03/09/2023] [Accepted: 03/18/2023] [Indexed: 06/24/2023]
Abstract
This is the second of two papers outlining the orthodontic management of patients with cleft lip and palate. The first paper reviewed orthodontic input into children with cleft lip and palate from birth to the late mixed dentition before definitive orthodontics. In this second paper, I will discuss tooth management across the grafted cleft site and its impact on the bone graft itself. I will also discuss the some of the challenges of the adult patient returning to the service.
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Affiliation(s)
- Toby Gillgrass
- Cleft Surgical Service for Scotland & Glasgow Dental Hospital and School, Glasgow, United Kingdom.
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Secondary Alveolar Bone Grafting in Patients with Unilateral and Bilateral Complete Cleft Lip and Palate: A Single-Institution Outcomes Evaluation Using Three-Dimensional Cone Beam Computed Tomography. Plast Reconstr Surg 2022; 149:1404-1411. [PMID: 35613289 DOI: 10.1097/prs.0000000000009142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Secondary alveolar bone grafting of autologous bone from the iliac crest is a widely accepted modality for repair of residual alveolar cleft in patients with mixed dentition with previously repaired complete cleft lip and palate. There remains debate regarding surgical timing and preoperative, perioperative, and postoperative management of these cases. METHODS This retrospective study reviewed patient demographic information in addition to preoperative, perioperative, and postoperative course to evaluate how patient and practice factors impact graft outcomes as assessed by three-dimensional cone beam computed tomographic evaluation at the 6-month postoperative visit. RESULTS On univariate analysis, age at operation older than 9 years, history of oronasal fistula, history of cleft lip or palate revision, and history of international adoption were all found to significantly increase likelihood of graft failure (p < 0.05). On multivariate analysis, age older than 9 years was found to be the single most significant predictor of graft failure (p < 0.05). There was no significant difference in graft outcomes between patients with unilateral or bilateral cleft lip and palate, and no single variable was found to significantly correlate to increased complication rates. The graft success rate overall of the authors' practice was 86.2 percent, with a complication rate of 7.7 percent. CONCLUSIONS Secondary alveolar bone grafting is an integral part of the cleft lip and palate surgical treatment series; this study identified several outcome predictors for both graft failure and adverse events, the most significant of which was age at operation. Although the mixed dentition phase often extends to 12 years of age, it is recommended that bone grafting be performed before 9 years of age to optimize outcomes. CLINICAL QUESTIONS/LEVEL OF EVIDENCE Risk, III.
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Stonehouse-Smith D, Beale V, Bellardie H. Radiographic outcome of secondary alveolar bone grafting in patients with alveolar clefts. Orthod Craniofac Res 2021; 25:128-133. [PMID: 34101345 DOI: 10.1111/ocr.12508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/29/2021] [Accepted: 06/03/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the outcome of secondary alveolar bone grafting (SABG) in a series of consecutive patients with clefts involving the alveolus. DESIGN AND SETTING Retrospective cohort study of consecutive operations performed between June 2011 and September 2016 by a single surgeon at a single United Kingdom cleft center. PARTICIPANTS A total of 160 patients with a cleft/s involving the alveolus, inclusive of syndromic patients and those with atypical facial clefts. INTERVENTIONS A standard protocol involved an oral hygiene program, pre-surgical orthodontics where necessary and autologous bone grafting from the iliac crest. MAIN OUTCOME MEASURE(S) The Kindelan bone-fill index was used to evaluate success using occlusal radiographs. Weighted Cohen's kappa coefficient was used as a measure of intra- and inter-rater agreement. Fisher's exact test was used to examine the effects of type of cleft, pre-surgical orthodontics or age at time of SABG on radiographic outcome. RESULTS There were 200 SABGs assessed. Mean age at time of SABG was 9.1 years old (SD 1.1) with 99% (n = 198) of grafts deemed successful. There were two failures where re-graft was performed successfully during the study period. A grade 1 outcome was achieved for 92.5% (n = 185) of grafts and this did not appear to be affected by type of cleft (P = .290), pre-surgical orthodontics (P = .380) or age at time of SABG (P = .081). CONCLUSIONS The high success rate reported in this study supports the favorable outcomes of a high-volume cleft surgeon. These findings can be used for comparative audit with similar units providing cleft care.
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Affiliation(s)
- Daniel Stonehouse-Smith
- Cleft Lip and Palate Unit, Royal Manchester Children's Hospital, Manchester, UK.,Department of Orthodontics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Victoria Beale
- Cleft Lip and Palate Unit, Royal Manchester Children's Hospital, Manchester, UK
| | - Haydn Bellardie
- Cleft Lip and Palate Unit, Royal Manchester Children's Hospital, Manchester, UK.,Faculty of Dentistry, Department of Orthodontics, University of the Western Cape, Cape Town, South Africa
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Skeletal and Dental Habilitation of Residual Alveolar and Maxillary Clefts. J Craniofac Surg 2021; 32:991-998. [PMID: 33481475 DOI: 10.1097/scs.0000000000007462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Management of residual clefts of the alveolus and maxilla requires the coordinated effort of multiple members of the craniofacial team including surgeon, orthodontist, and when teeth are hypoplastic or absent, the prosthodontist to achieve complete habilitation. Such cooperation among specialists begins early in the patient's life and continues through completion of care.Although numerous publications on this topic exist, few present definitive multidisciplinary reconstructive outcomes with longterm results. In this review paper, the authors present our comprehensive, multidisciplinary protocols, experience, and techniques as they have evolved with over 35 years of practice at our Craniofacial Center.Details of our updated protocols for each intervention and procedure, including our current thoughts on appropriate timing, follow up and advantages from the incorporation of current technologies are discussed. Close cooperation among specialists at all stages of care, the use of evolving technology, and adherence to, and modification where indicated, of time honored team protocols enables us to consistently achieve successful functional and esthetic outcomes, while minimizing complications.
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Vandersluis YR, Fisher DM, Stevens K, Tompson BD, Lou W, Suri S. Comparison of dental outcomes in patients with nonsyndromic complete unilateral cleft lip and palate who receive secondary alveolar bone grafting before or after emergence of the permanent maxillary canine. Am J Orthod Dentofacial Orthop 2020; 157:668-679. [PMID: 32354440 DOI: 10.1016/j.ajodo.2019.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 11/01/2019] [Accepted: 11/01/2019] [Indexed: 10/24/2022]
Abstract
INTRODUCTION For patients with complete unilateral cleft lip and palate (CUCLP), secondary alveolar bone grafting (SABG) can be performed before or after the emergence of the cleft side permanent canine (pre-CE and post-CE, respectively). The controversy regarding dental outcomes related to the timing of SABG remains unsettled. The objective of this study was to evaluate dental survival and specific dental outcomes of cleft-adjacent teeth in children with CUCLP who received either pre-CE or post-CE SABG. METHODS The permanent maxillary canines and the central and lateral incisors of 21 pre-CE and 23 post-CE SABG subjects with nonsyndromic CUCLP and all cleft-related surgeries performed by the same surgeon were analyzed retrospectively. Intraoral radiographs and clinical chart notes were collected at age 7 years, at the time of the SABG, and approximately 4 years after the grafting. Dental survival, spontaneous canine eruption, planned prosthetic replacement, root development, and root resorption were analyzed. RESULTS Dental outcomes on the noncleft side were better than those on the cleft side. On the cleft side, dental survival of the cleft-adjacent teeth was not significantly different between the pre-CE and post-CE SABG groups (P >0.05). Most teeth completed root development after grafting, and the cleft side canine root development in the pre-CE SABG group appeared to accelerate after SABG. Trends showed that the pre-CE SABG group suffered less root resorption (16.28%; post-CE: 22.73%; P >0.05) and received fewer planned prosthetic replacements (14.29%; post-CE: 26.01%; P >0.05) but required a greater number of canine exposures (33.33%; post-CE: 4.55%; P = 0.02). CONCLUSIONS Pre-CE SABG showed better dental outcomes in patients with CUCLP, with fewer adverse dental outcomes than post-CE SABG.
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Affiliation(s)
| | - David M Fisher
- Department of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kyle Stevens
- Department of Dentistry, Division of Orthodontics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bryan D Tompson
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada; Department of Dentistry, Division of Orthodontics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sunjay Suri
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada; Department of Dentistry, Division of Orthodontics, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Lowry CH, Long RE, Russell K, Giltner JQ, Weaver L, Mercado AM, Beals S, Beals P, Daskalogiannakis J, Hathaway RR, Doucet JC, Semb G, Shaw WC. The Effect of Earlier Bone Grafting, Prior to Orthodontic Treatment, on SWAG Ratings of Graft Outcomes. Cleft Palate Craniofac J 2020; 58:208-214. [PMID: 32812441 DOI: 10.1177/1055665620949433] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To compare the outcomes between 2 groups of patients with complete clefts treated with early secondary alveolar bone grafting (ABG) at 2 centers (5-7 years, before orthodontic intervention) and to a third group of patients treated at one of those centers (center 1) who had received later secondary ABG (8-10 years, after orthodontic intervention). DESIGN Blind retrospective analysis of cleft site radiographs using Americleft Standardized Way to Assess Grafts (SWAG) scale. PATIENTS A total of 99 patients with complete clefts from 2 North American cleft/craniofacial centers. INTERVENTIONS Secondary ABG representing 2 protocols: early grafting at a mean age of 6.6 years prior to any orthodontic intervention, and later grafting at a mean age of 10.2 years following pregrafting orthodontic intervention. MAIN OUTCOME MEASURES Using occlusal radiographs, the SWAG scale from 0 (failed graft) to 6 (ideal) was used. Six trained, calibrated raters scored each radiograph twice, with the average of the 2 ratings used as the final score. Reliability was assessed using the weighted κ statistic. The significance of differences between groups was determined using the Kruskal-Wallis test and Dunn test for pairwise comparisons. RESULTS Inter-rater reliability of SWAG method was good (0.631). Intra-rater reliability was excellent (0.817). There was a tendency for improved total graft outcome in the early grafted group from center 1 compared to the later grafted group with improvement being significantly different in only the coronal third of the early, preorthodontic grafted group. However, the difference was not statistically significant for the graft overall.
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Affiliation(s)
- Catherine H Lowry
- Department of Dental Medicine, Orthodontics, 6566Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Ross E Long
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
| | - Kathleen Russell
- Division of Orthodontics, Dalhousie University, Halifax, Nova Scotia, Canada.,Cleft Palate Team, IWK Health Centre, Halifax, Nova Scotia, Canada
| | | | - Lexi Weaver
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
| | - Ana M Mercado
- Division of Orthodontics, College of Dentistry, 2647The Ohio State University, Columbus, OH, USA
| | - Stephen Beals
- Barrow Cleft & Craniofacial Center, Phoenix, AZ, USA
| | | | - John Daskalogiannakis
- Department of Orthodontics, University of Toronto, Ontario, Canada.,Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronald R Hathaway
- Division of Plastic Surgery, Cincinnati Childrens Hospital, Cincinnati, OH, USA
| | - Jean-Charles Doucet
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA.,Department of Oral and Maxillofacial Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gunvor Semb
- University of Manchester, Manchester, United Kingdom.,OsloCleft-CraniofacialCenter, Norway
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Pinheiro FHDSL, Drummond RJ, Frota CM, Bartzela TN, Dos Santos PB. Comparison of early and conventional autogenous secondary alveolar bone graft in children with cleft lip and palate: A systematic review. Orthod Craniofac Res 2020; 23:385-397. [PMID: 32446283 DOI: 10.1111/ocr.12394] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/29/2020] [Accepted: 05/16/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The literature is scarce on studies comparing secondary alveolar bone graft (SABG) performed early at approximately 5-6 years and at the conventional time at 9-11 years. This systematic literature review(SLR) aimed to compare clinical outcomes after two different timings of SABG in children with unilateral and bilateral cleft lip and palate. METHODS The inclusion criteria were autogenous iliac grafts and the following study designs: case control, cohort, clinical controlled trial (CCT), randomized CCT (RCCT), and previous SLRs. Ovid MEDLINE, Ovid EMBASE, Web of Science, Scopus, Cochrane, ProQuest and Google Scholar were the primary databases. Two calibrated examiners worked independently to select the articles. The MINORS evaluation method for surgical non-RCTs was used to assess for quality. RESULTS 1,111 articles were retrieved and 19 qualified. Different clinical and radiographic outcomes such as bone level, periodontal status, canine eruption and cleft-side tooth survival were evaluated by different assessment methods such as CBCT volume, computed tomography, periodontal evaluation, panoramic, intraoral radiographs, and Bergland scale. No RCCT or meta-analysis was found. None of the studies received the ideal score, which is 16 for non-comparison studies and 24 for comparison studies. CONCLUSION Methodological variation, lack of standardization for initial cleft dimension and low-quality level rendered a fair comparison unfeasible. Although further studies are necessary, it can be assumed that early SABG also can be an acceptable option, but this was based on a single study with a reasonable level of evidence.
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Affiliation(s)
| | - Robert John Drummond
- Division of Orthodontics, Department of Preventive Dental Science, Faculty of Dentistry, University of Manitoba, Winnipeg, MB, Canada
| | - Carolina Martins Frota
- Division of Orthodontics, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo, Bauru, Brazil
| | - Theodosia N Bartzela
- Department of Orthodontics, Orthopedics and Pediatric Dentistry, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Doucet JC, Russell KA, Daskalogiannakis J, Mercado AM, Emanuele N, James L, Hathaway RR, Long RE. Facial Growth of Patients With Complete Unilateral Cleft Lip and Palate Treated With Alveolar Bone Grafting at 6 Years. Cleft Palate Craniofac J 2018; 56:619-627. [DOI: 10.1177/1055665618792791] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To investigate the effect that alveolar bone grafting (ABG) around 6 years of age has on facial growth by assessing craniofacial growth outcomes. Design: Retrospective cohort study. Setting: North American cleft centers. Participants: A total of 33 children with complete unilateral cleft lip and palate who were consecutively treated with secondary ABG around 6 years of age were compared to 148 participants from 4 centers with late secondary ABG. Methods: Preorthodontic standardized lateral cephalometric radiographs were analyzed and traced according to the Americleft Study protocol. Sixteen angular and 2 proportional measurements were performed. The outcomes of all ABG were assessed using the Standardized Way to Assess Graft scale. Measurement means from the study center (SC) were compared to 4 North American centers using analysis of variance and Welch modified t tests, and P < .05 was considered statistically significant. Results: For the SC, the mean age (SD) at the time of bone graft was 5.85 (0.71) years and the mean age at the time of the lateral cephalogram was 13.4 (1.8) years. The sagittal maxillary prominence of the SC was comparable to the 4 other centers. The mean SNA (78.1 [4.3]) for the SC was significantly higher compared to one center that used primary bone grafting ( P = .03). The soft tissue mean ANB (3.52 [4.09]) for the SC was significantly lower compared to 3 of the centers. Conclusions: Early secondary ABG around 6 years of age did not result in reduced midface projection as assessed by SNA and thus did not compromise anterior maxillary growth.
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Affiliation(s)
- Jean-Charles Doucet
- Department of Oral and Maxillofacial Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
- IWK Health Care Center, Cleft Palate Clinic, Halifax, Nova Scotia, Canada
| | - Kathleen A. Russell
- IWK Health Care Center, Cleft Palate Clinic, Halifax, Nova Scotia, Canada
- Division of Orthodontics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Daskalogiannakis
- Department of Orthodontics, University of Toronto, Toronto, Ontario, Canada
- Department of Dentistry, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ana M. Mercado
- Division of Orthodontics, Ohio State University, Columbus, OH, USA
| | - Nicholas Emanuele
- Department of Oral and Maxillofacial Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lindsay James
- Department of Oral and Maxillofacial Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ronald R. Hathaway
- Division of Craniofacial Plastic and Reconstructive Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Ross E. Long
- Lancaster Cleft Palate Clinic, Lancaster, PA, USA
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