A new scale to assess radiographic success of secondary alveolar bone grafts

Comparison of Alveolar Bone Grafting Outcomes using CBCT in Individuals with UCLP Based on the Presurgical Orthodontic Treatment Methods

OBJECTIVE

The purpose is to evaluate outcomes of alveolar bone grafting based on the pre-grafting orthodontic preparation methods.

DESIGN

Retrospective analysis of individuals with unilateral cleft lip and palate.

SUBJECTS AND SETTINGS

28 individuals with non-syndromic UCLP from two craniofacial centers, 14 individuals each from XXXX and XXXX.

INTERVENTIONS

The alignment group underwent maxillary expansion with incisors alignment while the non-alignment group underwent only maxillary expansion for presurgical orthodontic preparation.

METHODS

Initial and post-surgical CBCT scans were compared to observe changes in angulation of the incisor adjacent to the cleft site, alveolar bony root coverage, and bone graft outcomes.

RESULTS

In the alignment group, the buccolingual rotation decreased by 32.35 degrees (p = .0002), the anteroposterior inclination increased by 14.01 degrees (p = .0004), and the mesiodistal angulation decreased by 17.88 degrees (p = .0001). Alveolar bony coverage did not change after bone graft in both groups, and no difference was observed between the groups. Chelsea scale showed satisfactory bone graft outcome (category A, C) in 12 cases (85.71%) in the alignment group and 11 cases (78.51%) in the non-alignment group. The volumetric measurement showed the alignment group had better bone fill of 69.85% versus 51.45% in the non-alignment group (p = .0495).

CONCLUSIONS

Alveolar bony coverage on the tooth adjacent to cleft sites did not change with alveolar bone grafting surgery in either of the alignment and non-alignment group. Presurgical orthodontic alignment does not induce root exposure nor poorer bone grafting outcome.

Cone Beam-CT-Based Bone Volume Assessments of Alveolar Synthetic Bone Graft GlassBONE™ in Cleft Lip and Palate Patients: A Retrospective Study

Background

Clefts of the lip and palate (CLP) are facial deformities that require multiple surgical procedures during childhood. One of these steps consists of filling the alveolar space with bone graft, traditionally removed from the iliac crest. However, this procedure could be invasive in children.

Aim

Here, we aimed to evaluate the outcomes of GlassBONE™ graft, a bioactive glass used as a bone substitute, as an alternative to the deleterious autologous bone graft in children.

Materials & methods

Retrospective monocentric study with 17 children aged 7.5 ± 2.2 yo [3.8-13.3 yo] carrying CLP. This technique has been established at La Timone Children hospital (Assistance Publique - Hôpitaux de Marseille) since 2011. Clinical (scar, graft rejection and periodontal status) and radiological (both panoramic radiographs and cone beam-CT) follow-up was conducted one year after the graft. The primary outcome was the reduction of the cleft volume, and secondary was the eruption of the adjacent tooth through the graft.

Results

GlassBONE™ permitted a significant reduction in the cleft volume by 42.4 ± 27.7% [0.6-81.1%] (p < 0.0001), corresponding to a filling of 57.6 ± 27.7% of the alveolar cleft. GlassBONE™ is well tolerated, ensuring satifactory clinical results (improvement in both scar and periodontal coverage), as well as the physiological evolution of the germs through the biomaterial. GlassBONE™ appears particularly suitable for small volumes, and we were able to determine a minimum volume of approximtely 0.259 + / - 0.155 cc required for a successful bone fusion.

Conclusion

The bioactive glass GlassBONE™ could be safely used in children with small CLP cases, providing satisfactory clinical and radiological results.

The Effect of Platelet-Rich Fibrin and Platelet-Rich Plasma in Secondary Alveolar Bone Grafting in Cleft Lip and Palate Patients: A Systematic Review

(1) Background: Cleft lip, alveolus, and palate are the most common congenital abnormalities in the world, occurring in one in seven hundred live births. Secondary alveolar bone grafting (SABG) is usually performed when the permanent canine root shows one-half to two-thirds of root development. To improve the surgical outcome, supplemental grafting materials such as platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) have been used as an adjunct. This review is designed to assess the efficacy of PRF and PRP in improving the outcome of SABG. (2) Methods: A comprehensive literature search was performed until 13 October 2022 on MEDLINE, EMBASE, The Cochrane Library, and Pubmed. The full text of potentially relevant studies was reviewed, and only randomised clinical trials (RCTs) were included based on the inclusion criteria. (3) Results: A total of 656 studies were screened, of which four were included for final review. All of the four included studies that evaluated the quantitative or qualitative surgical outcome in varied ways. (4) Conclusions: Results of this review suggest that both PRF or PRP and control group (without the use of PRF/PRP) achieved similar successful outcomes in bone height, bone density, and bone volume in both qualitative and quantitative assessment.

Postoperative Radiologic Imaging in Secondary Alveolar Bone Grafting for Cleft Lip and Palate: A Systematic Review and Meta-Analysis

INTRODUCTION

Radiographs (XRs), computed tomography (CT) scans, and cone-beam CT (CBCT) scans are utilized for assessment of secondary alveolar bone graft (SABG) in patients with cleft lip and palate (CLP). However, the optimal choice for imaging modality remains unclear. This study compares the image fidelity and safety profile for XR, CT, and CBCT in the assessment of patients with CLP who have undergone SABG.

METHODS

Articles from MEDLINE and Elsevier Embase were screened. The primary outcome was graft success rate. Secondary outcomes were percent-by-volume of graft maintained and patient safety, defined by radiation exposure. A random effects model was used to calculate the pooled outcomes for each imaging modality. Chi-squared analysis was used to compare pooled outcomes between different imaging modalities.

RESULTS

Of the 149 articles identified initially, 14 were included. Computed tomography exhibited a significantly higher image fidelity demonstrated by a lower graft success rate (62.0%) compared with both XR (72.6%, P<0.01) and CBCT (69.8%, P<0.01). Cone-beam CT had the lowest reported percent-by-volume of graft maintained (32.1%). Computed tomography had a higher mean radiation dosage (39.7 milligray) than what has been reported for both XR and CBCT.

CONCLUSION

Computed tomography demonstrated lower graft success rates than both XR and CBCT, possibly indicating a higher image fidelity. However, compared with CBCT, CT may have a higher radiation exposure. Randomized trials and longitudinal studies are necessary to perform a direct comparison between CT and CBCT and to correlate the image fidelity of these modalities with clinical outcomes.

Early Results on the Efficacy of Demineralized Bone Matrix, Bone Morphogenic Protein, and Freeze-dried Bone Chips in Alveolar Cleft Repair

Background

Conventional treatment for alveolar cleft repair is done using autologous iliac crest alveolar bone graft (ABG). However, this method may not be ideal in all patients. Analysis of the efficacy of a mixture of demineralized bone matrix (DBX), bone morphogenic protein (rhBMP-2), and freeze-dried bone chips (FDBC) as an alternative for alveolar cleft repair was performed.

Methods

Consecutive patients from August 2019 to June 2022 undergoing early alveolar cleft repair, concomitant hard palate and alveolar cleft repair, secondary alveolar cleft repair, and regrafting from a previously failed ABG were analyzed. Computed tomography scans were performed to evaluate graft take at least 6 months postoperatively. Images were reviewed and scored. Alveolar graft height and graft thickness were recorded. A standardized scoring system was developed, with a score of 0 representing no graft take and 3 representing best possible graft take.

Results

Fifty-five consecutive alveolar clefts (43 patients) were identified as having undergone ABG and satisfied all the other inclusion criteria. Of these, 29 underwent first time ABG and 26 underwent redo ABG. The mean graft height and graft thickness recorded for all clefts was 2.2 and 2.0, respectively.

Conclusions

Early results evaluating the efficacy of ABG using DBX, rhBMP-2, and FDBC show feasibility in regard to both graft height and thickness when using a maxillary computed tomography scan to measure the bone graft take. These results suggest that DBX, rhBMP-2, and FDBC may act as a versatile bone graft material in cleft care, although further studies are needed to determine long-term outcomes.

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.

Radiographic Assessment of Cleft Alveolar Bone Defects: A Preliminary Comparison of Periapical and Cone Beam Computed Tomography Images

BACKGROUND & PURPOSE

Accurate radiographic assessment of secondary alveolar bone grafting (SABG) is critical in evaluating SABG outcomes in patients with cleft lip and palate. This study compared Periapical (PA) and Cone beam computed tomography (CBCT) grading of SABG outcomes and conducted an analysis of agreement rate between the two imaging modalities.

METHODS

A retrospective chart review was performed of patients who underwent secondary alveolar bone grafting at a single institution. Bone quality of the alveolar cleft site was assessed at three root levels of the adjacent teeth on PA and CBCT images.

RESULTS

48 patients had pre- or post-operative images with both CBCT and PA that were appropriate for comparison. A total of 174 alveolar bone sections (three root levels of adjacent teeth in 58 pairs) were graded on CBCT and PA images. Agreement of CBCT grading with PA grading was 41.3% (72/174) overall. CBCT assessments rated bone quality lower than PA grading in 51.2% (89/174) of sections. CBCT had higher grading than PA image grading in 7.5% (13/174) of sections. The weighted Cohen Kappa value for comparison of CBCT and PA readings was 0.17, indicating a low rate of agreement. Wilcoxon signed rank test demonstrated that the difference between grading on CBCT and PA assessments was statistically significant (P < .001).

CONCLUSIONS

CBCT and PA readings demonstrated an overall low rate of agreement in the assessment of cleft alveolar bone. This investigation suggests that PA radiographs have lower sensitivity in detecting poor bone grafting outcomes.

Core outcomes for orofacial clefts: reconciling traditional and ICHOM minimum datasets

OBJECTIVE/DESIGN/SETTING

This retrospective study sought voluntary participation from leading cleft centres from Europe and Brazil regarding core outcome measures. The results of this study would inform the debate on core outcome consensus pertaining to the European Reference Network for rare diseases (ERN CRANIO) and achieve a core outcome set for cleft care providers worldwide.

INTERVENTION/METHOD

Five orofacial cleft (OFC) disciplines were identified, within which all of the International Consortium of Health Outcomes Measurement (ICHOM) outcomes fall. One questionnaire was designed for each discipline and comprised 1. the relevant ICHOM's outcomes within that discipline, and 2. a series of questions targeted to clinicians. What core outcomes are currently measured and when, did these align with the ICHOM minimum, if not how did they differ, and would they recommend modified or additional outcomes?.

RESULTS

For some disciplines participants agreed with the ICHOM minimums but urged for earlier and more frequent intervention. Some clinicians felt that some of the ICHOM standards were compatible but that different ages were preferred and for others the ICHOM standards were acceptable but developmental stages should be preferred to absolute time points.

CONCLUSION/IMPLICATIONS

Core outcomes for OFC were supported in principle but there are differences between the ICHOM recommendations and the 2002 WHO global consensus. The latter are established in many centres with historical archives of OFC outcome data, and it was concluded that with some modifications ICHOM could be moulded into useful core outcomes data for inter-centre comparisons worldwide.

Evaluating SWAG and Its Validity When Compared to 3D Imagery of Secondarily Grafted Cleft Sites

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.

A Comparative Volumetric Assessment of Cancellous and Cortico-Cancellous Bone Graft in the Management of Unilateral Alveolar Cleft Defect using Cone Beam Computed Tomographic Scan-A Randomized Controlled Trial

Introduction

The most commonly preferred procedure for surgical correction of alveolar bone defect and restoration of bony contour is anterior iliac crest graft. Since the ancient time, cancellous bone graft is considered as a gold standard, but it has a high resorption rate and many other disadvantages, and hence we conducted this study to evaluate the efficacy of Cortico-cancellous bone graft harvested from anterior iliac crest to find out whether it can be used as a substitute for cancellous bone graft or not.

Aims & Objectives

The objectives of present study were to compare and evaluate the bone bridge formation rate, resorption rate, and uptake of bone graft at recipient site using cancellous and corticocanellous bone graft harvested from anterior iliac crest for complete unilateral cleft alveolus defects.

Patients and Method

Total 20 patients were divided into two groups by lottery method of randomization. Each group comprises of total 10 patients treated with cancellous bone graft in group 1 and corticocancellous bone graft in group 2 patients harvested from anterior iliac crest. Preoperatively and postoperatively CBCT scans were taken for each patient to calculate the volume of cleft defect and volume of newly formed bone after 6 months, respectively. Grafting fill rate was calculated and mean graft filling rate observed in the patients of group 1 was 1.14 ± 0.03, and in patients of group 2, it was 1.17 ± 0.03. The mean bone bridge formation rate observed in the patients of group 1 was 91.85 ± 0.81 and in patients of group 2 it was 87.89 ± 0.75. The mean bone resorption rate obtained in the patients of group 1 was 18.74 ± 0.42 and in patients of group 2 it was 16.87 ± 0.52.

Conclusion

The present study concluded that accurate estimation of the amount required for bone grafting in the alveolar cleft can be performed by CBCT scan data using Planmeca Romexis viewer version 5.0 software. Even though the corticocancellous bone graft has some drawbacks, it is equally good as cancellous bone graft because of its less resorption than cancellous bone graft and can be considered as a second best option for secondary alveolar bone grafting.Clinical trial registration no (REF/2020/09/031605)/(CTRI/2020/09/028001).

Efficacy of Demineralized Bone Matrix for Revision Alveolar Bone Grafting in Patients Previously Treated with Bone Morphogenetic Protein 2 (BMP-2)

OBJECTIVE

This study investigates the effectiveness of demineralized bone matrix (DBX) to close alveolar clefts in patients previously treated with bone morphogenic protein-2 (BMP-2) who remained with bone nonunion.

DESIGN

This is an IRB-approved retrospective, single-center study.

SETTING

This study was conducted at a tertiary academic center.

PATIENTS/PARTICIPANTS

We searched for all surgical encounters with the Current Procedural Terminology (CPT) code 42210 from the years 2013-2019. Included patients were diagnosed with cleft alveolus, previous BMP-2 exposure and required revision bone grafting during mixed dentition for persistent alveolar defects.

INTERVENTIONS

17 patients underwent revision alveolar bone grafting (ABG) with either DBX (n = 10) or autograft (n = 7) to repair persistent bony cleft.

MAIN OUTCOME MEASURE(S)

The primary study outcome measured was alveolar bone graft revision failure described as continued alveolar nonunion.

RESULTS

The median age at revision ABG was 13.1 ± 3.3 years, with a mean follow-up time of 4.9 years (1.1-9.2 years). Patients were 53% male, 47% had a unilateral cleft lip and alveolus. 58.8% of patients were treated with DBX in the cleft, 41.2% treated with autograft from iliac crest. Overall, 11.8% (n = 2) of all revisions failed, requiring a second revision. The average time to reoperation was 2.06 years, and both were re-grafted with autograft. There was no statistically significant difference between the type of bone graft source used and the failure rate obtained (P = .1544).

CONCLUSIONS

DBX and autologous iliac crest bone grafts achieve similar alveolar union rates during revision ABG in patients treated with previous BMP-2 to the alveolar cleft.

A Three-Dimensional Scale for the Qualitative and Quantitative Assessments of Secondary Alveolar Bone Grafting (SABG) in Unilateral Cleft Lip and Palate Patients Using Cone-Beam Computed Tomography (CBCT)

Background The objective of our study was to derive an objective assessment scale for three-dimensional (3D) qualitative and quantitative evaluation of secondary alveolar bone grafting (SABG) using cone-bone computed tomography (CBCT) in patients with unilateral cleft lip and palate (UCLP).

Methods CBCT scans for pre- and 3-month post-SABG were reviewed for bone volume, height, width, and density of the bony bridge formed in the cleft defect in 20 patients with UCLP. Basic descriptive and principal component analysis was used to extract the various sub-components of the scale. Spearman's correlation was used to check the validity of the scale, and intra-class coefficient (ICC) and Cronbach's α were calculated to establish the reliability and retest applicability of the scale.

Results Each CBCT scan was assessed in five areas: cementoenamel junction (CEJ), root apex, root midpoint, 3 and 6 mm below CEJ, and tabulated in percentiles of 20, 25, 40, 50, 60, and 75 for all the parameters (bone volume, density, and width). These scores were validated when correlated to the scale given by Kamperos et al. Cronbach's α for the domains demonstrated acceptable to excellent internal consistency. The ICC showed good test–retest reliability having a range of scores from 0.89 to 0.94.

Conclusion The proposed scale for the 3D assessment of SABG in patients with UCLP provides gradation for the objective assessment of the bony bridge. This gradation enables the qualitative and quantitative assessments of the bony bridge, thus allowing each clinician to judge SABG more conclusively.

Midpalatal suture bone repair after miniscrew-assisted rapid palatal expansion in adults

Background

Midpalatal suture (MPS) repair in growing patients after RPE has been previously reported. However, differences between young and adult patients for timing and pattern of MPS repair after rapid maxillary expansion are expected. The aim of this study was to evaluate the midpalatal suture repair pattern after miniscrew-assisted rapid palatal expansion (MARPE) in adult patients.

Materials and methods

The study included 21 patients (six males, 15 females) successfully treated with MARPE with a mean initial age of 29.1 years of age (SD = 8.0; range = 20.1–45.1). MPS repair was evaluated using maxillary axial and coronal sections derived from CBCT exams taken 16 months after the expansion (SD = 5.9). Objective and subjective assessments of MPS repair were performed. Objective assessments were performed measuring MPS bone density at anterior, median and posterior region of hard palate. Pre-expansion and post-retention bone density changes were evaluated using paired t tests (p < 0.05). Midpalatal suture bone repair was scored 0 to 3 considering, respectively, the complete absence of bone repair in the MPS, the repair of less than 50% of the MPS, the repair of more than 50% of the MPS and the complete repair of the MPS. Intra- and interexaminer reliability evaluation were assessed using Kappa coefficient.

Results

The objective evaluation showed a significant higher bone density at the pre-expansion stage in all palatal regions. The reliability of the subjective method was adequate with intra- and interexaminer agreements varying from 0.807 to 0.904. Scores 1, 2 and 3 were found in 19.05%, 38.09% and 42.86% of the sample, respectively. The most common region demonstrating absence of bone repair was the middle third. The anterior third of the midpalatal suture was repaired in all patients.

Conclusions

A decreased bone density was observed after the retention period when compared to pre-expansion stage. Most adult patients demonstrated incomplete repair of the midpalatal suture 16 months after MARPE. However, adequate bone repair covering more than half of the hard palate extension was observed in 80.95% of the patients.

Correlation between alveolar cleft morphology and the outcome of secondary alveolar bone grafting for unilateral cleft lip and palate

Background

Secondary alveolar bone grafting (SABG) is an integral part of the treatment for cleft lip and alveolus and cleft lip and palate. However, the outcome of SABG was not satisfactory as expected, factors that affecting the outcome were still controversial. The aims of this study were to summarize a new method for the classification of alveolar cleft morphology in patients with unilateral cleft lip and alveolus or unilateral cleft lip and palate, to evaluate the correlation between the morphology and SABG outcomes, to identify factors that might predict the outcomes.

Methods

The characteristics of the cleft morphologies of 120 patients who underwent SABG were observed using the preoperative Cone-Beam Computed Tomography (CBCT) images. 52 patients who had CBCT scans performed at least 6 months after SABG were included for the evaluation of outcomes. Both categorical and continuous evaluation methods were measured. Correlations between cleft morphology and SABG outcomes were assessed using the Pearson correlation coefficient in SPSS 27.0.0.

Results

A new method for the classification of cleft morphology was summarized:type I, prism type (labial defect size ≥ palatal defect size; nasal defect size ≥ occlusal defect size); type II, prism’ type (labial defect ≥ palatal defect; nasal defect < occlusal defect); type III, inverted prism type (palatal defect ≥ labial defect); type IV, funnel type (presented as a significantly narrow defect area in the middle towards the vertical dimension); and type V, undefinable (extremely irregular morphology can’t be defined as any of the above types). Categorical evaluation showed 8 failure, 11 poor, 12 moderate, and 21 good results, while the average bone filling rate was 59.24 ± 30.68%. There was a significant correlation between the cleft morphology and categorical/continuous evaluation outcome (p < 0.05).

Conclusion

The new method for the classification of alveolar cleft morphology summarized in this study was comprehensive and convenient for clinical application. Both categorical and continuous methods should be used for radiographic assessments in patients undergoing SABG. The chances of a successful procedure might be better when the patient has type I or IV morphology, in which the shape is like a funnel in the relatively palatal or occlusal area towards the vertical dimension. A relatively great amount of bone resorption was observed in most patients.

Trial registration Chinese clinical trial registry; registration number: ChiCTR2100054438.

"Improved Success Rate with Corticocancellous Block Compared to Cancellous-only Trephine Technique in Alveolar Bone Grafting from the Iliac Crest"

BACKGROUND

Alveolar bone grafting is an important component of cleft lip and palate treatment, with iliac crest as the most common donor site. Although studies have attempted to quantify alveolar bone graft resorption, few have directly compared the outcomes of graft techniques. This study compared the long-term success rates of corticocancellous block to trephine cancellous-only alveolar bone grafting from the iliac crest.

METHODS

A retrospective review of all cleft lip and palate patients undergoing alveolar bone grafting over 14 years was performed. Power analysis was performed to determine sample size. Data including patient demographics, surgical technique, need for repeat grafting, complications, length of hospitalization, and follow-up were collected. Statistical analyses of outcomes were performed based on initial graft technique.

RESULTS

A total of 106 initial operations met criteria, with 73 using trephine technique, 30 utilizing corticocancellous block, and 3 undergoing open cancellous harvest. The overall regraft rate was 40% with an average follow-up of 43.5 months. Patients with corticocancellous block grafting had significantly lower rates of repeat grafting compared to trephine technique (16.7% vs. 47.9%, p<0.001). There was no significant difference in complications rates or length of admission between treatment groups.

CONCLUSIONS

The use of corticocancellous block alveolar bone grafting demonstrated significantly higher success rates when compared to cancellous-only trephine techniques with no difference in complication rates. Although this must be weighed against the minor disadvantages of open iliac harvest, surgeons should consider incorporating en bloc corticocancellous bone to optimize outcomes in alveolar bone grafting.

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

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.

A Novel and Practical Protocol for Three-Dimensional Assessment of Alveolar Cleft Grafting Procedures

OBJECTIVE

To evaluate the reproducibility and accuracy of a new, easy-to-use volumetric assessment of the alveolar cleft.

DESIGN

Twelve cone-beam computed tomography (CBCT) datasets of patients with a unilateral cleft lip, alveolus, and palate were evaluated by two investigators. Residual alveolar cleft calcified volume one year after surgery was analyzed by using standardized landmarks to determine the borders of the cleft defect and semi-automatically segment the alveolar cleft defect.

RESULTS

The Dice-coefficient between observers for the segmented preoperative alveolar cleft defect was 0.81. Average percentage of residual alveolar cleft calcified material was 66.7% one year postoperatively.

CONCLUSIONS

This study demonstrates a reliable and practical semi-automatic three-dimensional volumetric assessment method for unilateral clefts using CBCT.

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.

Success rate of mid-secondary alveolar cleft reconstruction using anterior iliac bone grafts: A retrospective study

Introduction:

Bony reconstruction of the alveolar process and its adjacent platform largely represents the final step in surgical achievement of functionality and aesthetics in cleft patients. Throughout the years, the success of this procedure has been investigated. The aim of this study was to assess the success rate of autogenous mid-secondary alveolar bone grafting in this setting.

Methods and Material:

A retrospective cohort study was performed. All cleft patients receiving secondary alveolar bone grafts between 1990 and 2020 were reviewed. Criteria for assessing success were long-term preservation of alveolar bone stock, ability of spontaneous or orthodontic-guided eruption and periodontal health of permanent lateral incisors and canine teeth, absence of exposed root structures of neighbouring teeth, absence of fistula and successful placement of implants. Failure of alveolar bone grafts was indicated by radiographically demonstrable total or near-total graft loss requiring reintervention.

Results:

A number of 124 patients were included and grouped as those primarily operated following our (two-staged palatoplasty) protocol and those receiving cheilorhinoplasty and palatoplasty (one-staged) at other centres. Given the limited cohort size, no complex statistical analysis was performed. In the first group of 64 patients 12 experienced complications (Veau III, eight/36; Veau IV, four/18). In the second group of 60 patients, 12 experienced complications (Veau III, six/37; Veau IV, six/17).

Discussion:

Our surgical protocol using anterior iliac bone grafts for secondary alveolar reconstruction achieved good results, comparing favourably with previous literature.

Validation of a 3D methodology for the evaluation and follow-up of secondary alveolar bone grafting in unilateral cleft lip and palate patients

OBJECTIVE

The aim of the study was to propose and validate a method for three-dimensional (3D) quantitative assessment of secondary alveolar bone grafting (SABG) and its stability in time for patients with unilateral cleft lip and palate (UCLP).

SETTINGS AND SAMPLE POPULATION

Ten non-syndromic UCLP patients (9 males and 1 female with a mean age of 9.5 ± 0.9 years) undergoing SABG with good quality preoperative, immediate postoperative (6 weeks) and 6 months postoperative Cone Beam Computed Tomography (CBCT) scans were selected.

MATERIALS AND METHODS

The preoperative and 6 months postoperative scans were registered onto the immediate postoperative scan. The bone-grafted region was defined on the immediate postoperative scan and refined on the registered preoperative scan resulting in a 3D volume. The residual bone graft was calculated by applying threshold based segmentation on the registered 6 months postoperative scan within the segmented bone graft volume of the previous step. Inter and intra observer tests using intra-class correlation coefficient (ICC) were applied comparing the volumes of the 3D models.

RESULTS

An excellent reliability was found for inter and intra observers with ICC ≥ 0.95.

CONCLUSIONS

The presented method proved to be reliable for volumetric assessment of the alveolar bone graft in UCLP patients, as well as to assess the percentage of bone resorption during follow-up.

Safety and feasibility study of using polyphosphate (PolyP) in alveolar cleft repair: a pilot study

BACKGROUND

Bone grafting is an important surgical procedure to reconstruct alveolar bone defects in patients with cleft lip and palate. Polyphosphate (PolyP) is a physiological polymer present in the blood, primarily in platelets. PolyP plays a role as a phosphate source in bone calcium phosphate deposition. Moreover, the cleavage of high-energy bonds to release phosphates provides local energy necessary for regenerative processes. In this study, polyP is complexed with calcium to form Calcium polyP microparticles (Ca-polyP MPs), which were shown to have osteoinductive properties in preclinical studies. The aim of this study was to evaluate the feasibility, safety, and osteoinductivity of Ca-polyP MPs, alone or in combination with BCP, in a first-in-human clinical trial.

METHODS

This single-blinded, parallel, prospective clinical pilot study enrolled eight adolescent patients (mean age 18.1: range 13-34 years) with residual alveolar bone cleft. Randomization in two groups (four receiving Ca-polyP MPs only, four a combination of Ca-polyP MPs and biphasic calcium phosphate (BCP)) was performed. Patient follow-up was 6 months. Outcome parameters included safety parameters and close monitoring of possible adverse effects using radiographic imaging, regular blood tests, and physical examinations. Osteoinductivity evaluation using histomorphometric analysis of biopsies was not possible due to COVID restrictions.

RESULTS

Due to surgical and feasibility reasons, eventually, only 2 patients received Ca-polyP MPs, and the others the combination graft. All patients were assessed up to day 90. Four out of eight were able to continue with the final assessment day (day 180). Three out of eight were unable to reach the hospital due to COVID-19 restrictions. One patient decided not to continue with the study. None of the patients showed any allergic reactions or any remarkable local or systematic side effects. Radiographically, patients receiving Ca-polyP MPs only were scored grade IV Bergland scale, while patients who got the BCP/Ca-polyP MPs combination had scores ranging from I to III.

CONCLUSIONS

Our results indicate that Ca-polyP MPs and the BCP/Ca-polyP MPs combination appear to be safe graft materials; however, in the current setting, Ca-polyP MPs alone may not be a sufficiently stable defect-filling scaffold to be used in alveolar cleft repair.

TRIAL REGISTRATION

Indonesian Trial Registry under number INA-EW74C1N by the ethical committee of Faculty of Medicine, Hasanuddin University, Makassar, Indonesia with code number 1063/UN4.6.4.5.31/PP36/2019 .

Polyphosphate (PolyP) for alveolar cleft repair: study protocol for a pilot randomized controlled trial

Objective

Bone grafting is an important surgical procedure to restore missing bone in patients with alveolar cleft lip/palate, aiming to stabilize either sides of the maxillary segments by inducing new bone formation, and in bilateral cleft cases also to stabilize the pre-maxilla. Polyphosphate (PolyP), a physiological polymer composed of orthophosphate units linked together with high-energy phosphate bonds, is a naturally existing compound in platelets which, when complexed with calcium as Ca-polyP microparticles (Ca-polyP MPs), was proven to have osteoinductive properties in preclinical studies.

Aim

To evaluate the feasibility, safety, and osteoinductivity of Ca-polyP MPs as a bone-inducing graft material in humans.

Methods

This prospective non-blinded first-in-man clinical pilot study shall consist of 8 alveolar cleft patients of 13 years or older to evaluate the feasibility and safety of Ca-PolyP MPs as a bone-inducing graft material. Patients will receive Ca-polyP graft material only or Ca-polyP in combination with biphasic calcium phosphate (BCP) as a bone substitute carrier. During the trial, the participants will be investigated closely for safety parameters using radiographic imaging, regular blood tests, and physical examinations. After 6 months, a hollow drill will be used to prepare the implantation site to obtain a biopsy. The radiographic imaging will be used for clinical evaluation; the biopsy will be processed for histological/histomorphometric evaluation of bone formation.

Discussion

This is the first-in-man study evaluating the safety and feasibility of the polyP as well as the potential regenerative capacity of polyP using an alveolar cleft model.

Trial registration

Indonesian Trial Registry INA-EW74C1N. Registered on 12 June 2020

Radiographic outcome of secondary alveolar bone grafting in patients with alveolar clefts

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.

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.

The Effect of Earlier Bone Grafting, Prior to Orthodontic Treatment, on SWAG Ratings of Graft Outcomes

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.

An Accurate Volumetric Analysis Method for Evaluating Outcomes of Alveolar Cleft Reconstruction

An accurate volumetric analysis method for evaluating the outcomes of different types of alveolar cleft reconstruction is essential because it can help determine which graft material is more effective, confirm favorable times for alveolar bone grafting, and improve surgical techniques. This study aimed to introduce a novel method of precisely calculating the bone formation ratio using computer-aided engineering after surgery. A patient with a unilateral alveolar cleft who was treated with anterior iliac crest bone grafting was enrolled in this study. Helical computed tomography scans were performed preoperatively and 12 months postoperatively. The Digital Imaging and Communications in Medicine (DICOM) data were reconstructed as three-dimensional images and saved in the STL format by using Mimics software. STL data were processed by Geomagic Wrap 2017, using the Boolean operation, the newly formed bone of the alveolar was segmented by identifying the differences between the preoperative and the postoperative three-dimensional images. For this patient, the mean volume of the newly formed bone was 0.387 cm, the morphology was clear, the bone formation ratio was 41.4%, the mean time required for calculating the newly formed bone volume was 23 minutes, and the bone survival ratio was 38.7%. This method is a clinically practical, accurately measurement and time-saving method to evaluate the outcome of alveolar cleft reconstruction. Both the volumetric assessment and morphological analysis of the newly formed bone could be determined in a precise manner.

[Alveoloplasty and the use of osteosynthesis material in the cleft lip palate]

OBJECTIVES

To compare the results of secondary alveoloplasty performed in one Hospital when osteosynthesis material was used and when the bone graft does not require this material, and relating them to factors such as gender and age.

MATERIAL AND METHODS

A retrospective study was conducted from the years 2014 to 2019 in this Hospital on the selected patients who met the inclusion criteria. Two periods of ages, period A: ages between 5-12 years (mixed secondary alveoloplasty) and period B: greater than 12 years (late secondary alveoloplasty). Autologous bone from the iliac crest or parietal calotte was used for the bone graft. The patients were divided into 2 groups: group I: patients with alveoloplasties that required osteosynthesis material. Group II: patients who did not require osteosynthesis material. Parameters evaluated: the success criteria for alveoloplasty were assessed according to the clinical parameters described by Precious. Alveoloplasty was successful if they met all the criteria of Precious in the year of intervention. Postoperative complications in both groups were evaluated. The statistical analysis was performed using the exact Fisher test for qualitative variables.

RESULTS

Alveoloplasty was successful in 89.4% of patients in group I, while it was 90.3% in group II. Alveoloplasty was successful in 87.5% of females compared to 91.17% of males. The intervention was a success in 91.48% of patients in group A, compared to 66.6% in group B. The osteosynthesis material in two patients of group I was not degraded in the annual assessment. There were no significant differences in any of the comparisons.

CONCLUSIONS

The use of osteosynthesis material does not alter the integration of the bone graft in patients that undergo alveoloplasty. Factors such as gender or age do not influence the results of the interventions.

Surgical Outcomes of Secondary Alveolar Bone Grafting and Extensive Gingivoperiosteoplasty Performed at Mixed Dentition Stage in Unilateral Complete Cleft Lip and Palate

Secondary alveolar bone grafting (SABG) is associated with donor site morbidities. We aimed to compare the outcomes of SABG and extensive gingivoperiosteoplasty (EGPP) at the mixed dentition stage. This single-blinded, randomized, prospective trial enrolled 50 consecutive patients with unilateral complete cleft lip and palate who had residual alveolar bone cleft, of which 44 (19 SABG, 25 EGPP) completed the study. Bone volumes before surgery, 6 months postoperatively, and 1-year postoperatively were compared using computed tomography. The Bergland scale score was recorded at 6 months postoperatively. Both groups had the same preoperative alveolar cleft volume. On the Bergland scale, 21, 3, and 1 patient in the EGPP group and 16, 2, and 1 patient in the SABG group were classified as types I, II, and IV, respectively, which did not show significant difference. With perioperative orthodontic treatment, the 1-year residual bone defect volume in both groups did not show significant difference (SABG 0.12 cm³ vs. EGPP at 0.14 cm³, p > 0.05). The study was not able to reveal much difference between SABG and EGPP combined with perioperative orthodontic treatment.

A novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography

PURPOSE

Radiographic scales, based on plain radiographs, for the evaluation of alveolar cleft repair, have certain weaknesses and are thought to overestimate to some degree the success of the surgical intervention. The aim of this study was the presentation of a novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Patients treated with secondary osteoplasty for unilateral or bilateral alveolar cleft were evaluated using the Bergland and Enemark scales, as well as the novel success scale, which measures the bone height, the bone width and the level of the nasal floor.

RESULTS

A total of 44 patients with a total of 53 alveolar cleft sites were included. According to the new scale, 60% of the cases were defined as successful, with moderate (kappa = 0.511) or substantial (kappa = 0.718) agreement, between the new scale and the Bergland or Enemark scale, respectively. Statistically significant correlation was reported between the new success scale and the closure of space of the lateral incisor, the patient's age at surgery, the graft revision and the presence of residual fistula.

CONCLUSIONS

The novel success scale for evaluating alveolar cleft repair using CBCT takes into consideration all dimensions of the bony bridge. Future application is necessary for validation of its potential value.

Comparative Volume Analysis of Alveolar Defects by 3D Simulation

A precise volumetric assessment of maxillary alveolar defects in patients with cleft lip and palate can reduce donor site morbidity or allow accurate preparation of bone substitutes in future applications. However, there is a lack of agreement regarding the optimal volumetric technique to adopt. This study measured the alveolar bone defects by using two cone-beam computed tomography (CBCT)-based surgical simulation methods. Presurgical CBCT scans from 32 patients with unilateral or bilateral clefts undergoing alveolar bone graft surgery were analyzed. Two hands-on CBCT-based volumetric measurement methods were compared: the 3D real-scale printed model-based surgical method and the virtual surgical method. Different densities of CBCT were compared. Intra- and inter-examiner reliability was assessed. For patients with unilateral clefts, the average alveolar defect volumes were 1.09 ± 0.24 and 1.09 ± 0.25 mL (p > 0.05) for 3D printing- and virtual-based models, respectively; for patients with bilateral clefts, they were 2.05 ± 0.22 and 2.02 ± 0.27 mL (p > 0.05), respectively. Bland–Altman analysis revealed that the methods were equivalent for unilateral and bilateral alveolar cleft defect assessment. No significant differences or linear relationships were observed between adjacent different densities of CBCT for model production to obtain the measured volumes. Intra- and inter-examiner reliability was moderate to good (intraclass correlation coefficient (ICC) > 0.6) for all measurements. This study revealed that the volume of unilateral and bilateral alveolar cleft defects can be equally quantified by 3D-printed and virtual surgical simulation methods and provides alveolar defect-specific volumes which can serve as a reference for planning and execution of alveolar bone graft surgery.

Study on Tooth Movement After the Alveolar Bone Grafting in Patients With Unilateral Cleft Lip and Palate

OBJECTIVES

The aim of the study was to explore the effectiveness of the cleft-adjacent teeth moved into the grafted alveolar bone in unilateral cleft lip and palate (UCLP) patients, and to evaluate the alveolar bone support of the teeth.

METHODS

Twenty unilateral cleft lip and palate patients were recruited in this study. The average age was 12 years and 8 months. Periapical radiographs were taken for the cleft-adjacent teeth 3 months after bone grafting (T1) and after teeth moving into the grafted bone (T2), and for the contralateral teeth (T3) when teeth aligned. Alveolar bone support of the moved teeth and the contralateral teeth were measured using the ratio of bone support height to root length. Paired t test was performed for statistical analysis with SPSS17.0 software package.

RESULTS

All the cleft-adjacent teeth were bodily moved into the grafted area. Average alveolar bone support ratio for the moved teeth was 86.48% (T1), 87.11% (T2), and 90.81% (T3) for the contralateral teeth. There was no statistically significant difference between T1 and T2 (P > 0.05). Although the contralateral teeth had the highest alveolar bone support ratio, significant differences were found between T3 and T2 (P < 0.05).

CONCLUSIONS

Cleft-adjacent teeth could be bodily moved into the grafted bone from the iliac crest in UCLP patients. A successful level of alveolar bone support for the moved teeth was achieved. Moved-in teeth could be functionally loaded and may be benefit to the reduction of the resorption of grafted bone.

Current methods for secondary alveolar bone grafting assessment in cleft lip and palate patients - A systematic review

INTRODUCTION

The development of 3D X-ray diagnostics has led to new methods for secondary alveolar bone grafting (SABG) assessment. The aim of this study was to collect and present literature from the years 2007-2018, and review on the current treatment outcome assessment methods for SABG.

MATERIALS AND METHODS

A systematic review of literature from 2007 to 2018 was carried out, following PRISMA guidelines. 426 records were identified after duplicate references had been removed. 25 articles were included in the review. The Cochrane Collaboration tool or the methodological index for non-randomized studies was used for quality evaluation.

RESULTS

Computed tomography and cone beam computed tomography were preferentially used for SABG treatment outcome verification. There were different assessment protocols. Due to the ways in which results were presented, methods were divided into five groups: linear measurements, volumetric measurements, density measurements, percentage ratios, and scales. There was only one randomized, controlled trial with high methodological quality.

CONCLUSIONS

1. Currently, 3D X-ray imaging is a standard treatment outcome verification method for SABG. 2. It is necessary to establish the required postoperative follow-up time for best SABG treatment outcome assessment. More prospective studies to assess bone graft outcomes after 6 months and 1 year are required.

A Comparison between Piezoelectric Devices and Conventional Rotary Instruments in Bone Harvesting in Patients with Lip and Palate Cleft: A Retrospective Study with Clinical, Radiographical, and Histological Evaluation

Introduction

Orofacial clefts are congenital malformations characterized by an incomplete shaping of structures that separate the nasal from the oral cavity and can affect the right, left, or both sides. The aim of the present study is to assess, with clinical, radiographical, and histological evaluations, the efficacy of piezoelectric devices compared to traditional rotating instruments in the bone harvesting in patients with history of cleft.

Materials and Methods

We have conducted a retrospective analysis on 20 patients with a history of orofacial clefts that were operated on from February 2014 to June 2017. The patients were divided into two groups: Group R in which bone graft was harvested using a burr and Group P in which the bone graft was obtained by a piezoelectric device. After a healing period of 8 months from the grafting procedure, clinical and radiographic evaluations were performed.

Results and Discussion

The use of the piezoelectric devices in bone harvesting allows a slight improvement in the final volume. This supports a faster integration into the receiving site.

Conclusions

The use of piezoelectric device in patients with history of orofacial cleft that needed bone graft represents a method to be taken into consideration because it has interesting advantages.

Outcomes of Alveolar Graft With Rhbmp-2 in CLP: Influence of Cleft Type and Width, Canine Eruption, and Surgeon

OBJECTIVE

To evaluate the influence of cleft type and width, canine eruption stage, and surgeon on the outcomes of alveolar graft with rhBMP-2.

DESIGN

Cross-sectional.

SETTING

Tertiary craniofacial center.

PARTICIPANTS

Ninety individuals submitted to alveolar graft in late mixed or early permanent dentition.

INTERVENTIONS

The 90 individuals (mean age: 16.8 years) were submitted to alveolar graft with rhBMP-2. Periapical radiographs were obtained before and 6 months after surgery. Surgeries were performed by 4 experienced maxillofacial surgeons. The alveolar grafts were assigned as success or failure by 3 blinded raters based on the modified Bergland and Chelsea scales. Permanent canines adjacent to the defect were assigned as erupted and not erupted. The greatest cleft width was measured on preoperative periapical radiographs.

MAIN OUTCOME MEASURES

The influence of 4 independent variables (cleft type, cleft width, canine eruption phase, and surgeon) on the outcome of alveolar graft was analyzed by multivariate logistic regression ( P < .05).

RESULTS

All independent variables presented significant influence on alveolar graft outcome. The subgroup of unerupted maxillary canines demonstrated better outcomes than erupted canines ( P = .001). The group with cleft lip and alveolus (CL/A) demonstrated better outcomes than complete cleft lip and palate (CLP; P < .001). The greater the alveolar cleft width, the less favorable were the graft outcomes ( P = .027). The surgeon also had a significant influence on the surgery success ( P = .003 and .001).

CONCLUSION

The type and width of CLP, the eruption of permanent canines, and the surgeon influenced the outcome of alveolar graft surgeries performed with rhBMP-2.

Comparison of Reliability of Categorical and Continuous Scales for Radiographic Assessments of Bone Infill Following Secondary Alveolar Bone Grafting

OBJECTIVES

To investigate examiner reliability of scoring intraoral radiographs of bone infill following secondary bone grafting using a categorical scale (modified Kindelan Index) and a 10-cm visual analog scale (VAS). To investigate the level of clinical experience on the reliability of these assessments.

DESIGN

Retrospective study involving 10 clinicians of varying clinical experience who were blind to the patient's identity.

SETTING

All grafting was carried out within the New Zealand public hospital service.

PATIENTS

Fifty-eight grafts (48 UCLP and 5 BCLP) were assessed with 14 duplicated radiographs randomly added to the sample, making a total of 72 radiographs for assessment.

MAIN OUTCOME MEASURES

Weighted kappa was used for intra- and interrater examiner reliability for the categorical scale and correlations for the VAS.

RESULTS

Relatively poor intrarater examiner agreement for categorical scoring (median 0.46) was found. Clinicians with greater experience generally recording higher intrarater weighted kappa. The intrarater correlations for the continuous scale (median 0.89) suggest better consistency regardless of the level of experience. The interrater relationships were generally low, with an average of weighted kappa of 0.25 while the overall average VAS correlation was 0.49. For the majority of scorers, there was a relationship between the VAS and the Kindelan Index, with lower VAS scores related to worse Kindelan scores.

CONCLUSIONS

The use of a VAS produced better intra- and interexaminer reliability than the categorical Kindelan Index and was more consistent despite the level of clinical experience. Further evaluation of the validity of the VAS for the assessment of bone infill is warranted.

A Multicenter Study Using the SWAG Scale to Compare Secondary Alveolar Bone Graft Outcomes for Patients with Cleft Lip and Palate

Objective

To assess secondary alveolar bone graft (ABG) outcomes using the standardized way to assess grafts, or SWAG scale, for patients with cleft lip and palate (CLP).

Design

Retrospective cohort study.

Setting

Four cleft centers with different protocols.

Methods

One hundred sixty maxillary occlusal radiographs taken 3 to 18 months after secondary ABG for sequentially treated patients with CLP were assessed using the SWAG scale. Radiographs were scanned, standardized, blinded, and rated by six orthodontists using the SWAG scale. Randomized radiographs were rated twice, 24 hours apart, by the same raters.

Main Outcomes

Intrarater and interrater reliabilities were assessed. Means and SDs were calculated for ABG ratings using analysis of variance and Tukey tests (P < .05).

Result

The mean ABG age was 9.1 years (range = 7 to 10.1 years) and the mean follow-up age was 12.4 years (range = 8.2 to 20.4 years). Intrarater and interrater reliabilities were good (intrarater = 0.788, interrater = 0.705), and higher than published methods. Mean ABG ratings for the cleft centers were 4.53, 2.9, 3.63, and 5.0 and differed significantly. The two centers with the highest ABG ratings showed higher ratings for all thirds decreasing from apical to coronal. The two centers with lower ABG ratings showed poorer ABG ratings for all thirds, and the middle third received the highest ratings.

Conclusions

The SWAG scale overcomes the challenges of age and bone location. The SWAG method was validated for showing intercenter differences for overall bone fill as well as in vertical thirds. Surgical technique, timing, and expertise/volume were identified as possible factors related to outcome.

Secondary Alveolar Bone Grafting (CLEFTSiS) 2007–2010

Objective

To determine whether alveolar bone graft outcomes for unilateral and bilateral cleft lip and palate patients have continued to improve since the reorganization of cleft services in Scotland in 2000.

Design

Retrospective analysis of postoperative anterior occlusal radiographs. Patients and Participants: Eighty-one of 106 patients who were eligible for alveolar bone grafting between 2007 and 2010 had suitable postoperative radiographs available.

Interventions

Twenty-seven percent of the patients (n = 22) had presurgical orthodontic intervention. All patients underwent alveolar bone grafting with bone harvested from the iliac crest.

Main Outcome Measures

The Kindelan bone-fill index was used to evaluate success. Weighted kappa statistics were used to assess intra- and interobserver reproducibility. A comparison was made with results from 2000 to 2004 to assess any improvement. Chi-square tests (or Fisher exact test) were used to determine whether outcomes differed depending on the laterality of the cleft, use of presurgical expansion, or age at bone grafting.

Result

Interobserver scoring agreement was good (weighted kappa = .383). Intraobserver reproducibility was greater (weighted kappas of .835 and .620). Success was achieved in 99% of bone grafts, compared with 76% in the period from 2000 to 2004 (P < .001). There was no statistically significant relationship between the laterality of the cleft (P = 1.000), use of presurgical expansion (P = 1.000), or age at time of bone grafting and outcome (P = .259).

Conclusion

Scottish secondary alveolar bone graft outcomes improved during 2007 to 2010 in comparison to the 2000 to 2004 results.

An Evaluation of Alveolar Bone Grafting in the UK and Ireland

OBJECTIVE

To determine the main factors influencing the timing of alveolar bone grafting among cleft teams in the UK and Ireland, to assess the types of radiographs used to evaluate bone grafting sites pre- and postoperatively and the views of the profession on orthodontic expansion prior to grafting.

DESIGN

An online survey consisting of 24 questions was compiled and emailed to 53 orthodontists and surgeons in all 12 Cleft Hub Units in the UK and Ireland.

RESULTS

All units in the UK and Ireland responded with 51 responses, 39 complete and 12 partial responses, obtained from cleft surgeons and orthodontists. The majority of units are using dental criteria (75%) as a guide to timing alveolar bone grafting. Most units take a postoperative radiograph at 6 months but the view being taken varied. When asked if four cases were ready for grafting based on their radiographs, there was clear agreement by a significant majority for 3 cases but for 1 only a minimal majority (61%). The most common donor site chosen for the graft is the Iliac crest (92.9%). There was excellent agreement for 2 cases asking when to use expansion but poor agreement for one, 55% saying they would expand and 45% saying no.

CONCLUSION

Overall there is good agreement among cleft teams in the UK and Ireland about management of alveolar bone grafting; however, a clearer consensus on preoperative orthodontic expansion may be needed.

Factors Influencing Secondary Alveolar Bone Grafting in Cleft Lip and Palate Patients: Prospective Analysis Using CT Image Analyzer

Objective:

To examine the effect of migration of the germ of the lateral incisor into the bone for eruption factors on bone bridge resorption.

Methods:

Twenty-five subjects who underwent secondary alveolar bone graft were enrolled. The volume of the alveolar bone grafts immediately after the operation (V1), bone bridge formation 6 months postoperatively (V2), and tooth (teeth) migration into the bone bridge (Vt) were measured using a computed tomography (CT) image analyzer. Based upon these measurements, the following points were examined: (1) the correlation between the tooth-occupied ratio (Rt = Vt/V2 × 100) and the ratio of bone bridge resorption (Rv = (V1 − V2)/ V1 × 100); and (2) comparison of the tooth-occupied ratio (Rt) and the ratio of bone bridge resorption (Rv) between the groups with and without the germ of the lateral incisor.

Results:

A significant negative correlation was found between Rv and Rt (p < .001). Comparison of Rv and Rt between the groups with and without a germ of the lateral incisor revealed that both indices were significantly higher in the former group than the latter one (p < .05).

Conclusion:

In cleft lip and palate patients with a germ of the lateral incisor, it is beneficial to carry out secondary bone grafting to the alveolar cleft at the age of 5 to 7 years, preceding eruption of the canine, in order to form a good bone bridge that will facilitate eruption of the lateral incisor and subsequent normal dentition and occlusion.

Premaxillary Osteotomy and Guided Tissue Regeneration in Secondary Bone Grafting in Children with Bilateral Cleft Lip and Palate

Objective:

To introduce a surgical technique for secondary alveolar bone grafting performed in conjunction with premaxillary osteotomy and guided tissue regeneration in children with bilateral clefts. This paper also looks at the outcomes of this surgery in a series of 15 consecutive patients.

Methods:

Secondary alveolar bone grafting (with a premaxillary osteotomy and guided tissue regeneration with a collagen membrane) is usually carried out in the mixed dentition stage. This retrospective study used patients’ medical records, radiographs, and clinical examination to assess the outcome of the surgery. Patients were followed up for an average of 3 years.

Results:

Bone grafting was successful in all cases. No premaxillae were lost and there was no long-term morbidity of the donor site. Radiographic assessment of the bone heights showed an average of 94% retention, 3 months postoperatively. Preliminary assessment of maxillary canine eruption is encouraging, with 79% being fully erupted in those patients who are at least 3 years post–bone grafting.

Conclusion:

Premaxillary osteotomy allows repositioning of the premaxilla to its optimal preplanned position and successful closure of all fistulae. We have found that use of a collagen membrane is a useful adjunct.

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

Objective:

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

Design:

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

Interventions:

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

Results:

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

Conclusions:

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

Evaluation of Alveolar Bone Grafting: A Survey of ACPA Teams

Objective

To evaluate the management of alveolar clefts by cleft palate and craniofacial teams in North America.

Design

An anonymous survey was mailed to 240 American Cleft Palate– Craniofacial Association teams across North America regarding alveolar bone grafting. The questionnaire included multiple questions about each team's approach to alveolar bone grafting and options for the missing tooth.

Results

Consensus was achieved in three areas: 90% of centers performed secondary alveolar bone grafting, 78% performed grafting between ages 6 and 9 years, and iliac crest donor site was the most popular site (83%). There was no consensus with respect to dental criteria for the timing of grafting, follow-up x-rays, or the use of a grading system for evaluating results. In addition, there was no consensus on the management of the missing tooth.

Conclusion

There is wide acceptance of secondary bone grafting and there is a consensus for the age of grafting (6 to 9 years) and donor site (iliac crest). The disturbing finding was the lack of postoperative x-ray evaluation of the results. With so much variability in management, the use of a routine, standardized scale to measure postoperative results would allow for better outcome studies in alveolar bone grafting.

Ideal Versus Late Secondary Alveolar Bone Graft Surgery

Objective:

To compare the bone morphology after secondary alveolar bone graft surgery (SABG) performed before and after permanent canine eruption.

Design:

Cross-sectional study.

Setting:

Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, SP, Brazil.

Patients:

25 cone-beam computed tomography (CBCT) scans of complete unilateral cleft lip and palate (CLP) individuals who underwent SABG before or after eruption of the permanent canine taken 2 and 6 months (T1 and T2) after SAGB, resulting in 50 CBCT scans. Two groups were assessed, Ideal Group (IG; n = 10) and Late Group (LG; n = 15), according to the time of the SABG.

Interventions:

SABG buccal-palatal thicknesses were measured in 3 different root levels: cement-enamel junction (cervical slice), middle point of the root (intermediate slice), and apex of the central incisor (apical slice). Thickness measurements were assessed in the mesial, distal, and intermediate aspects of the alveolar bone graft. Clinical long-term follow-up was also done.

Results:

The IG showed significantly greater bone thickness, especially in the intermediate and apical slices, when compared to LG, in T1 and T2. Bone thickness was maintained over time. Clinically, all the IG individuals completed orthodontics, and no major complications were observed. In contrast, 27% of the LG individuals had failures, and rehabilitation was achieved through prosthesis.

Conclusion:

Ideal SABG presents with better results compared with late ABG. When it is not possible to perform SABG at the ideal time, acceptable outcomes still can be expected for late bone grafting.