Integrated Care Strategies for Unilateral Cleft Lip and Palate: A Multidisciplinary Treatment Approach for Profile Correction

Cleft lip and palate (CLP) is a prevalent congenital craniofacial deformity that can be unilateral or bilateral. This case report highlights the interdisciplinary approach to managing a 24-year-old male with unilateral CLP (UCLP), emphasizing the complexity of associated dental and skeletal challenges. The patient had undergone multiple surgeries, including lip closure at three months, palate repair at seven years, and alveolar bone grafting at 12 years. Clinical assessments revealed a retruded maxilla, an absence of lateral incisors, and scars from previous surgeries. Radiographic evaluations indicated a Class III skeletal pattern and confirmed the presence of a cleft on the left side. Orthodontic treatment commenced with maxillary arch alignment, followed by Le Fort I surgery to address maxillary retrusion, correct skeletal malocclusion, and close the alveolar cleft space. The post-surgical phase involved orthodontic adjustments, crossbite correction, and alignment of the mandibular arch. Despite the discontinuation of treatment due to the patient's relocation, the interdisciplinary collaboration achieved significant improvements, including a corrected facial profile, maxillary advancement, closure of the cleft space, and enhanced dental alignment. The patient's confidence and functionality were positively impacted. This case underscores the importance of a coordinated interdisciplinary approach to addressing the multifaceted challenges associated with UCLP, aiming to optimize both aesthetic and functional outcomes for improved patient well-being.

Microfragmented Fat and Biphasic Calcium Phosphates for Alveolar Cleft Repair: Protocol for a Prospective, Nonblinded, First-in-Human Clinical Study

BACKGROUND

Biphasic calcium phosphates (BCP) may serve as off-the-shelf alternatives for iliac crest-derived autologous bone in alveolar cleft reconstructions. To add osteoinductivity to the osteoconductive BCPs to achieve similar regenerative capacity as autologous bone, a locally harvested buccal fat pad will be mechanically fractionated to generate microfragmented fat (MFAT), which has been shown to have high regenerative capacity due to high pericyte and mesenchymal stem cell content and a preserved perivascular niche.

OBJECTIVE

Our primary objectives will be to assess the feasibility and safety of the BCP-MFAT combination. The secondary objective will be efficacy, which will be evaluated using radiographic imaging and histological and histomorphometric evaluation of biopsies taken 6 months postoperatively, concomitant with dental implant placement.

METHODS

Eight patients with alveolar cleft (≥15 years) will be included in this prospective, nonblinded, first-in-human clinical study. MFAT will be prepared intraoperatively from the patient's own buccal fat pad. Regular blood tests and physical examinations will be conducted, and any adverse events (AEs) or serious EAs (SAEs) will be meticulously recorded. Radiographic imaging will be performed prior to surgery and at regular intervals after reconstruction of the alveolar cleft with the BCP-MFAT combination. Biopsies obtained after 6 months with a trephine drill used to prepare the implantation site will be assessed with histological and histomorphometric analyses after methylmethacrylate embedding and sectioning.

RESULTS

The primary outcome parameter will be safety after 6 months' follow-up, as monitored closely using possible occurrences of SAEs based on radiographic imaging, blood tests, and physical examinations. For efficacy, radiographic imaging will be used for clinical grading of the bone construct using the Bergland scale. In addition, bone parameters such as bone volume, osteoid volume, graft volume, and number of osteoclasts will be histomorphometrically quantified. Recruitment started in November 2019, and the trial is currently in the follow-up stage. This protocol's current version is 1.0, dated September 15, 2019.

CONCLUSIONS

In this first-in-human study, not only safety but also the histologically and radiographically assessed regenerative potential of the BCP-MFAT combination will be evaluated in an alveolar cleft model. When an SAE occurs, it will be concluded that the BCP-MFAT combination is not yet safe in the current setting. Regarding AEs, if they do not occur at a higher frequency than that in patients treated with standard care (autologous bone) or can be resolved by noninvasive conventional methods (eg, with analgesics or antibiotics), the BCP-MFAT combination will be considered safe. In all other cases, the BCP-MFAT combination will not yet be considered safe.

TRIAL REGISTRATION

Indonesia Clinical Trial Registry INA-EW74C1N; https://tinyurl.com/28tnrr64.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42371.

Effect of adjuvant autologous platelet concentrates on secondary repair of alveolar clefts: A systematic review and meta-analysis

OBJECTIVE

To review the existing evidence on the adjuvant use of autologous platelet concentrates (APCs) with iliac crest bone graft (ICBG) in the reconstruction of the secondary alveolar cleft.

METHODS

Electronic databases were searched systematically until November 2022. Clinical trials comparing the three-dimensional radiological outcomes of patients who underwent secondary alveolar bone grafting (SABG) with ICBG and APCs to those with ICBG alone and the radiological outcomes assessed 6 months after surgery were included. Two authors performed the study selection and the assessment of the risk of bias. Meta-analysis was performed using the random-effects model to determine the risk ratio (RR) for developing wound dehiscence and the mean difference (MD) with a 95% confidence interval (CI) for the percentage of newly formed bone.

RESULTS

Nine studies (seven RCT and two CCT) were included with a low to high risk of bias. At the 6-month follow-up, the study group revealed insignificant results regarding the percentage of newly formed bone (MD = 6.49; 95% CI: -0.97, 13.94; p = .09; χ2  = 0.01; I2  = 71%). In addition, the overall risk of developing wound dehiscence was lower in the study group (RR = 0.34; 95% CI: 0.15, 0.78; p = .01; χ2  = 0.67; I2  = 0%).

CONCLUSION

Currently, there is insufficient evidence to support the adjuvant use of APCs with ICBG on enhanced bone regeneration following secondary alveolar bone grafting. However, combining ICBG and APCs might be beneficial in reducing the risk of developing wound dehiscence.

Evaluation of Eruption of Permanent Teeth in Beagle Dog Extraction Sites Filled with Carbonate Apatite

Autologous bone grafting is the primary method for treating alveolar clefts. However, bone grafting materials are desired as alternatives to autogenous bone to reduce surgical invasiveness. Here, we present an animal study evaluating the effect of carbonate apatite (CA) on the spontaneous eruption of permanent teeth. The bone grafting materials included CA, natural bovine bone (BB), and hydroxyapatite (HA). In 15 8-week-old male beagle dogs, the left mandibular deciduous premolars (DP) two and three were extracted and subsequently filled with CA, BB, and HA. The animals were euthanized after a predetermined number of days, and samples were collected for microcomputed tomography and histological evaluation. Spontaneous eruption of the succeeding permanent teeth (P3 and P4) was observed in the CA group at 14 weeks. Delayed eruption of the succeeding permanent teeth was observed in the BB and HA groups. CA could serve as a viable alternative to autogenous bone for treating alveolar clefts.

An easy-to-use semi-automatic volumetric evaluation for secondary bone grafting in patients with unilateral alveolar cleft

Surgical intervention for alveolar bone formation is important in patients with alveolar cleft; however, the treatment methods and materials are still controversial. A precise evaluation method for postoperative bone formation is important for comparing outcomes and establishing the best treatment protocol. The purpose of this study is to establish a new method of evaluating surgical outcomes for patients with alveolar cleft. Computed tomography datasets from 20 patients who underwent secondary alveolar bone grafting were obtained before and 1 year after surgery. Six anatomical landmarks were used to superimpose the preoperative and mirrored preoperative volume and postoperative volume data. The cleft region was segmented by subtracting the preoperative from mirrored preoperative volume data, and the failed osteogenesis region was segmented by subtracting the postoperative volume data from the cleft region; subsequently, the bone formation ratio was calculated. Two observers performed this method using a free software 3D slicer and the average evaluation times were 12.7 and 13.2 min for observers 1 and 2, respectively. Method reliability was determined by evaluating intraclass correlation coefficients. The intra-observer intraclass correlation coefficients were 0.97 and 0.96 for observers 1 and 2, respectively. The inter-observer intraclass correlation coefficient was 0.97. Our method is practical for assessing bone formation after treatment, which does not require specific knowledge or software and can be used by ordinary physicians.

Evaluation of a Granular Bone Substitute for Bone Regeneration Using an Optimized In Vivo Alveolar Cleft Model

Alveolar cleft is a common congenital deformity that requires surgical intervention, notably using autologous bone grafts in young children. Bone substitutes, in combination with mesenchymal stem cells (MSCs), have shown promise in the repair of these defects. This study aimed to evaluate the regenerative capabilities of a granular bone substitute using an optimized alveolar cleft model. Thirty-six rats underwent a surgical procedure for the creation of a defect filled with a fragment of silicone. After 5 weeks, the silicone was removed and the biomaterial, with or without Wharton's jelly MSCs, was put into the defect, except for the control group. The rats underwent μCT scans immediately and after 4 and 8 weeks. Analyses showed a statistically significant improvement in bone regeneration in the two treatment groups compared with control at weeks 4 and 8, both for bone volume (94.64% ± 10.71% and 91.33% ± 13.30%, vs. 76.09% ± 7.99%) and mineral density (96.13% ± 24.19% and 93.01% ± 27.04%, vs. 51.64% ± 16.51%), but without having fully healed. This study validates our optimized alveolar cleft model in rats, but further work is needed to allow for the use of this granular bone substitute in the treatment of bone defects.

The Effect of Platelet-Rich Plasma on Bone Volume in Secondary Alveolar Bone Grafting in Alveolar Cleft Patients: A Systematic Review

This systematic review aims to investigate the impact of platelet-rich plasma (PRP) in conjunction with bone grafting on bone volume outcomes in secondary alveolar bone grafting (SABG) procedures among alveolar cleft patients. An exhaustive search involving PubMed, Cochrane, and Google Scholar databases yielded 20 relevant titles, ultimately leading to the inclusion of four articles meeting all specified criteria. Based on the Cochrane risk of bias in systematic reviews (ROBIS) tool, the studies showed a high risk of bias. The primary outcome, bone volume assessment, was analyzed across these articles. While the Cochrane ROBIS tool deemed the included articles to have a high risk of bias, the comparison between PRP and Non-PRP groups did not reveal a significant difference in bone volume. Radiographic data illustrated an initial three-month period of bone resorption post-graft, regardless of PRP application, followed by a six-month phase of heightened bone density, particularly discernible in the PRP groups. To sum up, our findings indicate an absence of substantial bone density increase in cleft patients undergoing SABG with PRP augmentation. Nonetheless, there was a modest trend that suggests potential incremental bone density improvement with PRP usage, underscoring the need to conduct rigorously designed, randomized controlled trials (RCTs) with low bias to validate these observations.

Consequence of Synthetic Bone Substitute Used for Alveolar Cleft Graft Reconstruction (Preliminary Clinical Study)

Background  The outcome of alveolar grafting with synthetic bone substitute (Osteon III) in various bone defect volumes is highlighted. Methods  A prospective study was accomplished on 55 patients (6-13 years of age) with unilateral alveolar bone cleft. Osteon III, consisting of hydroxyapatite and tricalcium phosphate, is used to reconstruct the defect. Alveolus defect diameter was calculated before surgery (V1), after 3 months (V2), and finally after 6 months (V3) postsurgery. In the t -test, a significant difference and correlation between V1, V2, and V3 are stated. A p- value of 0.01 is considered a significant difference between parameters. Results  The degree of cleft is divided into three categories: small (9 cases), medium (20 patients), and large (26 cases).The bone volume of the clefted site is divided into three steps: volume 1: (mean 18.1091 mm 3 ); step 2: after 3 months, volume 2 resembles the amount of unhealed defect (mean 0.5109 mm 3 ); and the final bone volume assessment is made after 6 months (22.5455 mm 3 ). Both show statistically significant differences in bone volume formation. Conclusion  An alloplastic bone substitute can also be used as a graft material because of its unlimited bone retrieval. Osteon III can be used to reconstruct the alveolar cleft smoothly and effectively.

Three-dimensional reconstruction reveals the correlation between the extent of alveolar clefts and secondary nasal deformity in adults

OBJECTIVES

This study aimed to explore the relationship between alveolar cleft and secondary nasal deformity post unilateral cleft lip repair in adults.

METHODS

A total of 27 patients aged 16-30 years old with unilateral secondary nasal deformity and alveolar cleft were included, 13 of whom underwent bone grafting. Spiral CT data of all preoperative and postoperative patients who had alveolar bone grafting were collected. Then, Mimics software was used for three-dimensional reconstruction to evaluate the correlation between the width, height, and volume of the alveolar cleft and those of the nasal deformity. The difference in nasal deformity before and after alveolar bone grafting was also explored.

RESULTS

The width of the alveolar cleft was positively correlated with the difference in bilateral nostril floor width (P<0.05). As the effective depth of the alveolar cleft increased, the sub-alare inclination angle largened (P<0.05). However, no significant difference was found in the nasal deformity between before and after alveolar bone grafting.

CONCLUSIONS

Alveolar cleft is closely related to secondary nasal deformities post unilateral cleft lip repair, especially nasal floor deformities. Alveolar bone grafting benefits adult patients for the improvement of secondary nasal deformities post unilateral cleft lip repair.

Effectiveness of iliac cancellous bone grafting in alveolar cleft repair and analysis of factors affecting it

OBJECTIVES

To review the effectiveness of secondary alveolar bone grafting using iliac cancellous bone in patients with unilateral complete alveolar cleft and to investigate the factors influencing it.

METHODS

A retrospective study of 160 patients with unilateral complete alveolar clefts who underwent iliac cancellous bone graft repair at the Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, was conducted. Eighty patients in the young age group (6-12 years) and 80 in the old age group (≥13 years) were included. Bone bridge formation was determined using Mimics software, and the volume was measured to calculate the iliac implantation rate, residual bone filling rate, and resorption rate. The factors that affected bone grafting in both subgroups were investigated.

RESULTS

Using bone bridge formation as the clinical success criterion, the success rate for the entire population was 71.25%, with a significant difference of 78.75% and 63.75% for the young and old age groups, respectively (P=0.036). The gap volume in the latter was significantly larger than that in the former (P<0.001). The factors that influenced bone grafting in the young group were the palatal bone wall (P=0.006) and history of cleft palate surgery (P=0.012), but only the palatal bone wall affected the outcome in the old age group (P=0.036).

CONCLUSIONS

The results of alveolar bone grafting for the old age group were worse than those for the young age group. The palatal bone wall was an important factor that affected alveolar bone grafting, and alveolar bone grafting in the young patients was influenced by the history of cleft palate surgery.

Stem Cell-Based Tissue Engineering for Cleft Defects: Systematic Review and Meta-Analysis

This study aimed to analyze the efficacy of stem cell-based tissue engineering for the treatment of alveolar cleft (AC) and cleft palate (CP) defects in animal models.

Systematic review and meta-analysis.

Preclinical studies on alveolar cleft repair in maxillofacial practice.

Electronic search was performed using PubMed, Embase, and Cochrane databases. Pre-clinical studies, where stem cell-based tissue engineering was used in the reconstruction of AC and CP in animal models were included. Quality of the selected articles was evaluated using SYRCLE (SYstematic Review Centre for Laboratory animal Experimentation).

Review of alveolar cleft bone augmentation interventions in preclinical models.

Outcome parameters registered were new bone formation (NBF) and/or bone mineral density (BMD).

Thirteen large and twelve small animal studies on AC (21) and CP (4) reconstructions were included. Studies had an unclear-to-high risk of bias. Bone marrow mesenchymal stem cells were the most widely used cell source. Meta-analyses for AC indicated non-significant benefits in favor of: (1) scaffold + cells over scaffold-only (NBF P = .13); and (2) scaffold + cells over empty control (NBF P = .66; BMD P = .31). Interestingly, dog studies using regenerative grafts showed similar to superior bone formation compared to autografts. Meta analysis for the CP group was not possible.

AC and CP reconstructions are enhanced by addition of osteogenic cells to biomaterials. Directions and estimates of treatment effect are useful to predict therapeutic efficacy and guide future clinical trials of bone tissue engineering.

Postoperative Daycare as a Safe and Cost-Effective Option for Secondary Alveolar Bone Graft (SABG) Surgery: A Retrospective Comparative Cohort Study

OBJECTIVE

To evaluate the outcomes of Secondary Alveolar Bone Grafting (SABG) in patients treated either in daycare or with multiple day hospitalization (MDH) in relation to costs and complication rates.

DESIGN

Retrospective comparative cohort study.

SETTING

The data was collected from two settings: Postoperative daycare or MDH after oral cleft surgery in an Academic Medical Center in The Netherlands.

PATIENTS

Data of 137 patients with unilateral Cleft lip, alveolus, and palate (CLAP) treated between 2006-2018 were evaluated. Registered clinical variables: age, gender, cleft subtype, bone donor site, type of hospitalization, length of stay, additional surgery, complications, surgeons, and costs.

INTERVENTIONS

Closure of the alveolar cleft with/without closure of the anterior palate.

MAIN OUTCOME MEASURES

Univariate analyses.

RESULTS

Of the 137 patients, 46.7% were treated in MDH, and 53.3% in daycare. Total costs for daycare were significantly lower (P < .001). All patients treated in daycare received mandibular symphysis bone, whereas in MDH, 46.9% received iliac crest bone instead. Bone donor site was associated with postoperative care type. Complication rates were slightly but not significantly higher in daycare (26%) vs. MDH (14.1%) (P = .09). Most were Grade I (minor) according to Clavien Dindo classification.

CONCLUSIONS

Daycare after alveolar cleft surgery is about as safe as MDH, but significantly cheaper.

Two-stage alveolar bone grafting for nasal floor reconstruction in adult cleft patients

Alveolar cleft is one of the key links of cleft lip and palate reconstruction due to its close relationship with tooth and jaw coordination and nasolabial deformity. The alveolar bone graft repairs the hole in the gum ridge and stabilizes the bone arch, providing better support for the base of the nose and new bone for the roots of the developing teeth to grow into. Unfortunately, bone graft failure in the traditional way, even among minor clefts, bony hypoplasia, or absence that affects the nasal base and piriform rim, is common. Two-stage alveolar bone grafting, which has advantages in addressing the underlying skeleton and deficiency, could be an optional surgical procedure for nasal floor reconstruction in adult patients with a broad alveolar cleft.

3-Dimensional Craniofacial Imaging: A Template for Systematic Radiologic Evaluation for Alveolar Cleft Assessment and Planning

BACKGROUND

Imaging findings are central to the diagnosis and treatment planning decisions when managing craniofacial differences. However, limited information is published on protocols for systematic cleft imaging assessment and for effective communication of these findings.

SOLUTION

A template is presented to help guide radiologic imaging reports to acquire the relevant clinical information needed to manage patients with alveolar cleft.

Preliminary efficacy analysis of block iliac bone grafting in patients with alveolar cleft in mixed dentition

OBJECTIVES

To investigate the efficacy of block iliac bone grafting in patients with unilateral alveolar cleft in mixed dentition.

METHODS

A retrospective study was conducted on patients with unilateral alveolar clefts in mixed dentition who were treated in the Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital. All patients underwent unilateral alveolar cleft bone graft repair with autogenous block iliac bone blocks. The healing of bone blocks was analyzed at 1 week and 6-12 months after surgery. Mimics software was used for the three-dimensional reconstruction and volumetric measurement of the iliac bone blocks on the follow-up imaging data of 15 patients aged 9-12 years without the eruption of canines before surgery, and the bone resorption rate of the iliac bone blocks was comparatively analyzed.

RESULTS

In the 37 patients, bone grafting was successful in 32 and failed in five. The success rate of bone grafting was 86.5%. In 15 patients aged 9-12 years without the eruption of canines before surgery, eruption through the bone graft area was observed in two patients 6-12 months after the operation. Cone beam computer tomography showed that the grafted bone block exhibited good bony connections, and its resorption mainly occurred on the crests and palatal sides of the alveolar ridge. Bone resorption rates varied considerably between patients with a mean bone resorption rate of 39.0%±13.8% at 6-12 months after surgery.

CONCLUSIONS

For patients in mixed dentition, bone grafting with block iliac bone can achieve better osteogenesis effect.

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.

Construction of a Pig Alveolar Cleft Model in Imitation of Cleft Lip and Palate Congenital Deformity

Alveolar cleft repair is a key step in multiple disciplinary treatment for patients with cleft lip/and palate. Although autologous bone grafting has been used worldwide over the past half century, alternative advanced techniques, such as the use of bone substitutes and guided tissue regeneration, have shown their great potentials and have been recommended by a growing number of physicians and surgeons. The employment of new therapeutic approaches and devices in clinical routine requires tremendous experimental efforts and appropriate animal models with similar sizes and sites of deformity to that of human both anatomically and physiologically. The aim of this study is to develop a juvenile porcine model with surgically created alveolar clefts imitating congenital alveolar cleft in the cleft lip and palate. Alveolar defects between second incisor and canine were surgically created in two miniature pigs (unilateral cleft in P1 and P2); bilateral alveolar defects were surgically created between first and third incisor in one miniature pig (P3) using piezo surgery. Pigs were sacrificed (P1 at 1 month after the surgery and P2 at 3 months postoperatively) and the evaluation of defects were performed by assessing result from the computed tomography (CT) scan and histopathological examination. Postoperative CT scan results showed that the size of the defect remained the same, whereas the edge of the defect became irregular 3 months after the surgery. In all pig subjects, histopathological examination found no sign of osteogenesis in the area of defect, indicating that our surgical procedure was successful in establishing porcine models for alveolar cleft in congenital cleft lip and palate. In conclusion, we developed alveolar cleft in porcine models to mimic the size, site, and environment of congenital alveolar cleft in cleft lip and palate. The novel animal model can be employed in pilot studies for the purpose of optimizing the current surgical treatment techniques as well as developing new treatment procedures and test the bone substitute materials. The bilateral model can be applied in further control studies. Impact statement Cancellous iliac bone graft was the most popular surgical technique as well as the gold standard to reconstruct alveolar cleft. Nevertheless, several disadvantages exist regarding the additional surgical field of donor side and delayed age of alveolar bone grafting. Bone tissue-engineered strategy offers a promising alternative to address the gap in the current limitation of autologous bone to treat the growing craniofacial skeleton. Among different species of laboratory animals, porcine is suitable for oral and maxillofacial bone and implant-related research, where alveolar defect can be surgically developed simulating the size and site of alveolar cleft occurring together with cleft lip and palate. In this proposal, a reproducible porcine model of alveolar bone defect imitating congenital alveolar cleft during craniofacial growing stage is successfully constructed that will show great potential application in the field of tissue engineering and regenerative medicine. The model for bilateral alveolar cleft can be potentially applied in a controlled study in future.

Mimicked Periosteum Layer Based on Deposited Particle Silk Fibroin Membrane for Osteogenesis and Guided Bone Regeneration in Alveolar Cleft Surgery: Formation and in Vitro Testing

An alveolar cleft is a critical tissue defect often treated with surgery. In this research, the mimicked periosteum layer based on deposited silk fibroin membrane was fabricated for guided bone regeneration in alveolar cleft surgery. The deposited silk fibroin particle membranes were fabricated by spray-drying with different concentrations of silk fibroin (v/v): 0.5% silk fibroin (0.5% SFM), 1% silk fibroin (1% SFM), 2% silk fibroin (2% SFM), and 1% silk fibroin film (1% SFF) as the control. The membranes were then characterized and the molecular organization, structure, and morphology were observed with FT-IR, DSC, and SEM. Their physical properties, mechanical properties, swelling, and degradation were tested. The membranes were cultured with osteoblast cells and their biological performance, cell viability and proliferation, total protein, ALP activity, and calcium deposition were evaluated. The results demonstrated that the membranes showed molecular transformation of random coils to beta sheets and stable structures. The membranes had a porous layer. Furthermore, they had more stress and strain, swelling, and degradation than the film. They had more unique cell viability and proliferation, total protein, ALP activity, calcium deposition than the film. The results of the study indicated that 1% SFM is promising for guided bone regeneration for alveolar cleft surgery.

Progressive Comparison of Density Assessment of Alveolar Bone Graft in Patients with Unilateral and Bilateral Cleft

(1) Background: Continuing to observe the grafted bone mineral density (BMD) is essential to ensure the success of alveolar bone grafting (ABG) in patients with cleft lip and palate. This study elaborates on three methods that can be used to evaluate the progressive BMD. (2) Methods: Forty patients with unilateral or bilateral clefts receiving ABG were enrolled. Cone beam computed tomography (CBCT) scans were taken at 6 months (T1) and 2 years (T2) postoperatively. In CBCT, measurements were obtained on three different planes using the circle located 1 mm from the adjacent teeth (Method A), the largest circle within the defect (Method B), or the central circle with a diameter of 2 mm (Method C). The BMD was the average density of the three planes and was adjusted by pogonion density. Bland–Altman plots were used to evaluate the agreement of each method. Inter-rater reliability was confirmed by the intraclass correlation coefficient (ICC). (3) Results: For Method A, B, and C, the mean-adjusted BMD (BMD/pogonion density, BMD_a) was 17.44%, 17.88%, and 17.69%, respectively, at T1 (p = 0.495), and 22.51%, 22.87%, and 22.74%, respectively, at T2 (p = 0.690); the density enhancement rates were 40.54%, 38.92%, and 43.15% (p = 0.382). Significant differences between the BMD_a at T1 and T2 were observed (p < 0.001, <0.001, and 0.001, for Method A, B, and C, respectively). The volume of the grafted tissue remained stable during T1 and T2, and no significant correlation between density enhancement rate and volume loss was observed. (4) Conclusions: A significant increase in the BMD of grafted tissue was observed in the 2-year postoperative follow-up. The three methods for measuring BMD_a via CBCT can be applied in post-ABG evaluations.

Repair of alveolar cleft bone defects in rabbits by active bone particles containing modified rhBMP-2

Objective: A model of alveolar cleft phenotype was established in rabbits to evaluate the effect of active bone particles containing modified rhecombinant human BMP-2 on the repair of the alveolar cleft. Methods: 2-month-old Japanese white rabbits were selected and randomly divided into four groups: normal, control, material and BMP groups. Blood biochemical analysis, skull tomography (microfocus computerized tomography), and histological and immunohistochemical staining analysis of paraffin sections were performed 3  and 6 months after operation. Results: Both types of collagen particles showed good biocompatibility and promoted bone regeneration. The effect of active bone particles on bone repair and regeneration was better than that of bone collagen particles. Conclusions: Active bone particles containing modified rhecombinant human BMP-2 can be used for incisors regeneration.

Mechanical Tension-Stress in Alveolar Cleft Repaired With Autogenous Bone in Canine Models

OBJECTIVE

Cleft lip and/or palate is a common birth defect worldwide, always accompanied by alveolar cleft. However, the success rate of secondary alveolar bone grafting is unsatisfactory. Rapid maxillary expansion (RME) often used after bone transplantation provides functional stimulation for bone graft area. This study aimed to investigate the effect of RME force on the bone graft area and midpalatal suture, and screen out the most suitable loaded force and loaded teeth, so as to provide a reference for clinical treatment.

METHODS

Fourteen 24-week-old male beagles were assigned randomly to 3 groups: blank control, autogenous, and autogenous with RME. Three-dimensional finite element analysis was conducted to evaluate the distribution and value of the stress in the model. The maxillae were collected and subjected to radiography and helical computed tomography to evaluate new bone formation in the graft area. Van Gieson's Picrofuchsin staining was performed for histomorphological observation.

RESULTS

After 8 weeks of RME treatment, new bone formation of the dogs was markedly accelerated, and bone resorption was significantly reduced compared with the untreated dogs or those only treated with autogenous iliac bone. The treatment with RME evidently made the bone trabecula more abundant and the area of bone formation larger. Three-dimensional finite element analysis showed that the clinical effect can be achieved by using canine teeth as the loaded teeth and applying force of 10 MPa.

CONCLUSION

Rapid maxillary expansion after bone grafting had a positive effect on osteogenesis in a canine model of alveolar cleft.

Pain management at iliac donor sites after grafting of alveolar clefts

The aim of this study was to answer the question: which analgesic protocol is most efficient and most effective in overcoming pain and promoting functional recovery after iliac bone grafting in cleft alveolus patients? A systematic review of the literature was performed. The population consisted of cleft lip and alveolus patients with or without cleft palate undergoing iliac crest bone grafting; the outcomes analysed were represented by the duration of hospital stay, subjective pain rating, and degree of impaired mobility. A total of 15 articles were selected for review. The following protocols were subject to comparison in this review: simple classic intravenous/per-oral analgesia, local anaesthetic infiltration in the donor site, anaesthetic-soaked sponge, neural blocks and continuous infusion at the donor site. The results of the included studies were individually reported identifying trends in the efficiency of the different pain-management techniques. Although hospital stay varied from same-day discharge to almost a week, other factors besides pain influenced this outcome. School was resumed after an average of 12.6 days and sport activities after maximum one month regardless of the used protocol. Even though the age of patients had a statistically significant influence on hospital stay durations, it did not determine the latter. The pain management protocols after iliac bone grafting of alveolar clefts selected for analysis have their advantages and drawbacks. All protocols seem effective meaning they reach adequacy in managing pain at the donor site. The efficiency of the protocols could not be assessed due to the lack of data and inconsistency in pain assessment scales. Further investigation through randomized controlled studies is required.

A Novel Bone Substitute Based on Recombinant Type I Collagen for Reconstruction of Alveolar Cleft

This study aimed to examine the optimal cross-link density of recombinant peptide (RCP) particles, based on human collagen type I, for bone reconstruction in human alveolar cleft. Low- (group 1), medium- (group 2), and high- (group 3) cross-linked RCP particles were prepared by altering the duration of the heat-dependent dehydration reaction. Rat palatine fissures (n = 45), analogous to human congenital bone defects, were examined to evaluate the potential of bone formation by the three different RCP particles. Microcomputed tomography images were obtained to measure bone volume and bone mineral density at 4, 8, 12, and 16 weeks post grafting. Specimens were obtained for histological analysis at 16 weeks after grafting. Additionally, alkaline phosphatase and tartrate acid phosphatase staining were performed to visualize the presence of osteoblasts and osteoclasts. At 16 weeks, bone volume, bone mineral density, and new bone area measurements in group 2 were significantly higher than in any other group. In addition, the number of osteoblasts and osteoclasts on the new bone surface in group 2 was significantly higher than in any other group. Our results demonstrated that medium cross-linking was more suitable for bone formation—and could be useful in human alveolar cleft repairs as well.

Orthodontic Pre Grafting Closure of Large Alveolar Bony and Soft Tissue Gaps: A Novel Nonsurgical Protraction of the Lesser Segments in Growing Patients With Cleft Lip and Palate

BACKGROUND

Closure of wide alveolar clefts with large soft tissue gaps and reconstruction of the dentoalveolar defect are challenging for the surgeon. Some authors successfully used interdental segmental distraction, which requires an additional surgical procedure.

OBJECTIVE

This study evaluates the effectiveness of tooth borne devices utilized to orthopedically advance the lesser segments, with a complete approximation of the soft tissue of the alveolar stumps, allowing traditional simultaneous soft tissue closure and bone grafting, and avoiding the need for supplementary surgery.

METHODS

Eight growing patients, 2 with unilateral complete cleft lip and palate (UCLP) and 6 with bilateral complete cleft lip and palate (BCLP), with large soft tissue and bony alveolar defects prior to bone grafting were prospectively selected. A banded rapid palatal expander (RPE) in BCLP and a modified RPE in UCLP combined with protraction face mask in younger patients or a modified Alt-Ramec in patients older than 12 years were applied. Radiographic and photographic records were available at T0, at the end of protraction (T1) and at least 1 year after bone grafting (T2).

RESULTS

Patients with large gaps showed a significant reduction in the bony cleft area and approximation of the soft tissues at T1. All patients received bone grafting with good healing and ossification at T2.

CONCLUSION

In growing patients with UCLP and BCLP with large gaps, presurgical orthodontic protraction seems to be an efficient method to reduce the cleft defect, minimizing the risk of post grafting fistulas, reducing the need for supplementary surgical procedures.

Regeneration in Experimental Alveolar Bone Defect Using Human Umbilical Cord Mesenchymal Stem Cells

Cleft lip and palate is a congenital disorder including cleft lip, and/or cleft palate, and/or alveolar cleft, with high incidence.The alveolar cleft causes morphological and functional abnormalities. To obtain bone bridge formation and continuous structure between alveolar clefts, surgical interventions are performed from infancy to childhood. However, desirable bone bridge formation is not obtained in many cases. Regenerative medicine using mesenchymal stem cells (MSCs) is expected to be a useful strategy to obtain sufficient bone bridge formation between alveolar clefts. In this study, we examined the effect of human umbilical cord-derived MSCs by transplantation into a rat experimental alveolar cleft model. Human umbilical cords were digested enzymatically and the isolated cells were collected (UC-EZ cells). Next, CD146-positive cells were enriched from UC-EZ cells by magnetic-activated cell sorting (UC-MACS cells). UC-EZ and UC-MACS cells showed MSC gene/protein expression, in vitro. Both cells had multipotency and could differentiate to osteogenic, chondrogenic, and adipogenic lineages under the differentiation-inducing media. However, UC-EZ cells lacked Sox2 expression and showed the lower ratio of MSCs than UC-MACS cells. Thus, UC-MACS cells were transplanted with hydroxyapatite and collagen (HA + Col) into alveolar cleft model to evaluate bone formation in vivo. The results of micro computed tomography and histological staining showed that UC-MACS cells with HA + Col induced more abundant bone formation between the experimental alveolar clefts than HA + Col implantation only. Cells immunopositive for osteopontin were accumulated along the bone surface and some of them were embedded in the bone. Cells immunopositive for human-specific mitochondria were aligned along the newly formed bone surface and in the new bone, suggesting that UC-MACS cells contributed to the bone bridge formation between alveolar clefts. These findings indicate that human umbilical cords are reliable bioresource and UC-MACS cells are useful for the alveolar cleft regeneration.

Changes in maxillary dental arch morphology after implant treatment in the alveolar cleft region

Background

Few reports have examined dental arch morphology (DAM) after dental implant placement in cleft patients and its actual state is unclear.

Objective

To analyze the presence of changes in DAM and influencing factors in cleft lip and/or palate (CLP) patients who receive implant treatment in the alveolar cleft region.

Methods

Subjects comprised 20 CLP patients in whom maxillary dental arch width (DAW) was evaluated before and after implant treatment based on computed tomography data. First, widths between the canines (W3), between the first premolars (W4), between the second premolars (W5), and between the first molars (W6) were measured before and after surgery. Changes in distance were analyzed using the Wilcoxon signed‐rank test, revealing a significant increase in W6. Analysis of Co‐Variance was performed with the difference in W6 after implant treatment as the response variable, and the following six items as explanatory variables: sex; cleft type; age at alveolar bone graft; time to implantation after bone grafting; number of implants; and time after completion of the observation period.

Results

The reduction in W6 was larger in the order of complete bilateral CLP, complete unilateral CLP, and unilateral cleft lip and alveolus, and the change decreased with an increasing number of implants.

Conclusions

Implant treatment of the alveolar cleft region may result in a slight reduction in width of the dental arch after treatment completion.

Alveolar Cleft Reconstruction Using Morphogenetic Protein (rhBMP-2): A Systematic Review and Meta-Analysis

OBJECTIVE

This study aimed to review the existing evidence regarding reconstruction of the alveolar cleft using recombinant human bone morphogenetic protein-2 (rhBMP-2) in terms of bone volume and bone height.

DESIGN

Systematic review and meta-analysis.

PATIENTS—PARTICIPANTS

A systematic search was done. Randomized and nonrandomized clinical trials, where rhBMP-2 was used in the reconstruction of human alveolar cleft were included.

INTERVENTIONS

Reconstruction of alveolar cleft with rhBMP-2.

MAIN OUTCOME MEASURES

Average bone volume formation and average bone height formation in the alveolar cleft. Mean difference was calculated and pooled by meta-analysis.

RESULTS

Of 709 identified articles, 5 studies met the inclusion criteria. The average bone volume formation was higher in the rhBMP-2 group than in the control group (61.11% vs 59.12%). The average bone height formation was higher in the control group compared to the rhBMP-2 group (75.4% vs 61.5%). The risk of bias in the selected articles was high. The meta-analysis showed that rhBMP-2 treatment may benefit bone formation compared to iliac crest graft (low certainty evidence; mean difference: -208.76; 95% confidence interval: -253.59 to -163.93; -I² = 0%).

CONCLUSIONS

The results obtained in primary articles are promising but have a high risk of bias and have low quality of evidence; therefore, it is necessary to conduct controlled clinical trials with a greater number of patients to recommend the use of rhBMP-2 in the treatment of the alveolar cleft. PROSPERO registration number: CRD42018077741.

Eighteen-Year Follow-Up of 160 Consecutive Individuals Born With Unilateral Cleft Lip or Cleft Lip and Alveolus Treated by the Oslo Cleft Lip and Palate Team

OBJECTIVE

Describe patients born with unilateral cleft lip with or without cleft alveolus (CL±A) in relation to cleft severity and laterality, gender, associated anomalies and syndromes, number and type of lip- and nose operations, and time of alveolar bone graft (ABG) treatment in relation to dental status in cleft area.

MATERIALS AND METHODS

Patients included 220 children born with unilateral CL±A, born between 1988 and 1997 referred to the Oslo Cleft Lip and Palate Team. The data were collected retrospectively. All patients were followed up until 18 years of age.

RESULTS

Among all CL±A, 3.6% had recognized syndromes, 6.8% had associated anomalies, and in 89.6% CL±A was the only malformation. CL±A was more common, but not more severe, on the left side. Among the 160 individuals with CL±A without syndromes and associated anomalies, 66.9% had an isolated soft tissue CL, and 33.1% were diagnosed with a CL alveolus (CL+A). Male predominance was observed. Children with CL+A had more severe soft tissue clefts of the lip and underwent more lip and nose surgeries than children born with CL. The time of ABG was found to be at a younger age when the patient had a lateral incisor in the cleft area than when this tooth was missing.

CONCLUSION

Findings provide a reference for morphologic variations in CL±A, and insight into the surgical burden of care until the age of 18 years.

Microstructured beta-tricalcium phosphate for alveolar cleft repair: a two-centre study

The current standard of care in alveolar cleft repair is timing the procedure in the mixed dentition stage and making use of autologous bone to restore the maxillary defect. Using a synthetic bone substitute bypasses the risk of donor site morbidity and reduces the operation time. In this study, the outcome of alveolar cleft repair using microporous beta-tricalcium phosphate (β-TCP) was investigated in patients with unilateral cleft lip and palate. Twenty patients were enrolled prospectively in this study, divided between two centres. Continuity of the alveolar process, recurrence of oronasal fistulas, and eruption of teeth into the repaired cleft were evaluated at 1year postoperative. Also, cone beam computed tomography scans were analyzed using a volume-based semi-automatic segmentation protocol. No adverse events were reported. The mean residual bone volume in the repaired cleft at 1year postoperative was 65%. There was no recurrence of oronasal fistula. Furthermore, 90% of the teeth adjacent to the cleft erupted spontaneously and all patients showed a continuous alveolar process. Secondary alveolar grafting using microporous β-TCP can safely be used in the clinical situation. Residual calcified tissue, canine eruption, and complication rates at the recipient site are comparable to those with autologous grafts.

An Unusual Case of an Odontogenic Keratocyst Associated With an Ungrafted Alveolar Cleft: A Case Report and Review of the Literature

We describe an unusual case of an odontogenic keratocyst (OKC) associated with an ungrafted left-sided alveolar cleft in a 10-year-old male patient. There is no previous report in the literature of OKC or other dental cysts associated with an alveolar cleft. We discuss the management of the OKC prior to secondary bone grafting and present this case to highlight the difficulty in the management of OKC concurrent with grafting of the alveolar cleft site, the proximity of unerupted permanent teeth, and possible treatment modalities.

Evaluation of osteoinductive calcium phosphate ceramics repairing alveolar cleft defects in dog model

BACKGROUND

Alveolar cleft repair is an important step in the sequence of treatments for cleft lip and palate. Intrinsically osteoinductive materials have been the subject of research interest.

OBJECTIVE

The aim of this study was to explore the use of osteoinductive biphasic calcium phosphate (BCP) ceramics to repair alveolar cleft defects in dogs.

METHODS

We prepared two kinds of BCP ceramic with different physical characteristics: osteoinductive BCP (OBCP) and non-osteoinductive BCP (NBCP). Bilateral alveolar cleft models were surgically established in dogs. On one side, OBCP was implanted in the defect; on the opposite side NBCP was implanted as a control. The materials were also implanted in the femoral muscles to test their properties at non-osseous sites. The osteogenic ability of materials was evaluated with imaging, spiral CT, histology and fluorescent dye tests.

RESULTS

At the muscular implantation sites, new bone formed in all of the OBCP samples, but none in the NBCP samples. Imaging and spiral CT revealed good appearance and continuity of the alveolar cleft postoeration, with normal eruption of the bilateral permanent teeth in the groups. Histological and fluorescent dye testing revealed new bone formation in both groups in situ. However, earlier osteogenesis initiation and bone remodeling were superior with OBCP. Osteogenic process in the intramuscular samples with OBCP was similar to that seen in situ.

CONCLUSIONS

Our findings indicated that osteoinductive biphasic calcium phosphate ceramics (OBCP) have superior characteristics in alveolar cleft repair compared with non-osteoinductive calcium phosphate ceramics (NBCP).

A Tip for the Reconstruction of Larger Maxillary Defects in Complicated Cleft Patients

Residual alveolar cleft deficits can be difficult to treat. This is particularly the case in older and multiply operated patients as well as those with large oronasal defects and extensive scar tissue. In large and recalcitrant defects vascularized free tissue transfer should be considered as a definitive procedure. Vascularized free tissue transfer provides a 95% success rate and provides excellent bone for placement of osseointegrated implants for dental rehabilitation (Schwabegger et al., 2004). We feel that the scapula tip has a number of important advantages. These include reduced morbidity from the donor site, good bone quality and contour for implant placement, and a longer pedicle length.

Microstructured β-Tricalcium Phosphate Putty Versus Autologous Bone for Repair of Alveolar Clefts in a Goat Model

For the first time it was demonstrated that an osteoinductive calcium phosphate-based putty is effective in the restoration of complex maxillofacial defects. In these defects, adequate mechanical confinement by multiple bony walls and osteoconduction from multiple surfaces are usually lacking. This study compares the efficacy of a microstructured beta-tricalcium phosphate (β-TCP) putty with autologous bone for the repair of alveolar cleft defects. A total of 10 Dutch milk goats were operated on in a split-mouth study design in which two-wall bony alveolar clefts were created and successively repaired with autologous bone (the gold standard) at one side and β-TCP putty at the other. After 24 weeks of implantation, histomorphometric and micro-computer tomography analyses proved that the β-TCP putty group showed equal bone quality and volume to clefts reconstructed with autologous bone. In addition, surgical handling of the putty is superior to the use of calcium phosphates in a granular form. Therefore, the results of this study open a clear trajectory for the clinical use of β-TCP putty in the reconstruction of the alveolar cleft and other challenging two-wall bony defects.

Does Platelet-Rich Fibrin Enhance Bone Quality and Quantity of Alveolar Cleft Reconstruction?

BACKGROUND

Recently, platelet-rich fibrin (PRF) was described as a second-generation platelet concentrate. PRF is known as a rich source of autologous cytokines and growth factors and is universally used for tissue regeneration in clinical medicine.

OBJECTIVE

The aim of the current study was to evaluate the effect of PRF on the quality and quantity of bone formation in unilateral maxillary alveolar cleft reconstruction.

PATIENTS AND METHODS

Twenty-four patients with unilateral alveolar cleft underwent bone reconstruction. Patients were randomly divided into two groups. Group A consisted of patients grafted with PRF combined with autogenous anterior iliac crest bone graft. Group B patients were grafted using autogenous bone graft alone (control group). Computed tomography was performed 6 months postoperatively to assess the quality and quantity of the newly formed bone.

RESULTS

The percentage of newly formed bone (quantity) in group A ranged from 79.74% to 88.4%, with a mean percentage of 82.6% ± 3.9%. In group B, the percentage of bone formation ranged from 60.3% to 76.4%, with a mean percentage of 68.38% ± 6.67%. There was a statistically significant increase in the percentage of newly formed bone in group A. The mean bone density (quality) of the newly formed bone was lower in group A than group B, but the difference was not statistically significant (P < .05).

CONCLUSIONS

PRF in combination with autogenous bone was beneficial in improving the volume of newly formed bone in alveolar cleft reconstruction and does not enhance bone density.

Demineralized bone matrix for alveolar cleft management

The aim of this article is to describe the results of the use of demineralized bone matrix putty in alveolar cleft of patients with cleft lip and palate. We performed a prospective, descriptive case series study, in which we evaluated the results of the management of alveolar clefts with demineralized bone matrix. Surgery was performed in 10 patients aged between 7 and 26 years (mean 13 years), involving a total of 13 clefts in the 10 patients. A preoperative cone beam computed tomography (CBCT) was taken to the patients in whom the width of the cleft was measured from each edge of the cleft reporting values between 5.76 and 16.93 mm (average, 11.18 mm). The densities of the clefts were measured with a CBCT, 6 months postoperative to assess bone formation. The results showed a register of gray values of 1,148 to 1,396 (mean, 1,270). The follow-up was conducted for 15 to 33 months (mean, 28.2 months). The results did not show satisfactory bone formation in the cleft of patients with the use of demineralized bone matrix.

Alveolar bone grafting: past, present, and new horizons

Alveolar bone grafting is an important part of the reconstructive journey for many cleft lip and palate patients. The reconstruction of the alveolar cleft can provide both aesthetic and functional benefits to the patient. To be able to effectively treat alveolar clefts, it is essential to possess an understanding of several aspects of the problem. Acquiring this knowledge will allow the provider to treat the different variants of the cleft alveolus. In this article, the author will discuss anatomy, history, techniques, controversies, and new technologies to provide the reader with new insight into treating this challenging condition.

Evaluation of bone volume after secondary bone grafting in unilateral alveolar cleft using computer-aided engineering

The purpose of this study was to evaluate the initial defect and the outcome of bone grafts for unilateral alveolar cleft. To determine the absorption of the bone graft in patients with unilateral cleft, computer-aided engineering (CAE) with multi-detector row computed tomography (MDCT) was used. MDCT scans of 29 patients were taken immediately preoperatively and at 1 month and 6 months postoperatively. The patients underwent bone grafting between 8 and 14 years of age using iliac crest bone grafts. Three-dimensional models were created in each period, and the defect at the alveolar cleft and volume of the bone graft were determined in each patient using CAE. Cleft volume and success of alveolar bone grafting were significantly correlated (P < .01). Alveolar clefts with cleft palate required more bone volume than those without cleft palate (P < .01), but the resorption rate did not significantly differ between alveolar clefts with and without cleft palate (0.48 ± 0.14 and 0.49 ± 0.18, respectively; P = .93). In conclusion, three-dimensional reconstruction of bone grafts using CAE based on MDCT provides a valuable objective assessment of graft volume.