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.

Primer on State Statutory Mandates of Third-Party Orthodontic Coverage for Cleft Palate and Craniofacial Care in the United States

Provision and timing of orthodontic treatment is a crucial part of comprehensive cleft palate and craniofacial care. Some states statutorily mandate orthodontic coverage for the medically necessary care of cleft palate and craniofacial anomalies. However, application of the medically necessary standard varies broadly. Disputes over medical necessity lead to orthodontic coverage denials and surgical intervention delays. Provider-friendly statutory definitions of medical necessity enable patients and providers to avoid such hurdles. The objective of this study is to evaluate state mandates and highlight language favorable to patients and providers.

Occlusal relationship in patients with bilateral cleft lip and palate during the mixed dentition stage: does neonatal maxillary arch configuration predetermine outcome?

OBJECTIVE

To determine whether there is any correlation between initial maxillary arch dysmorphology patterns in complete bilateral cleft lip/palate (BCLP) and the subsequent occlusal relationship in early mixed dentition.

DESIGN

This retrospective study evaluated 41 consecutive patients with complete BCLP who were managed by a single tertiary cleft team between 1983 and 1992. All patients had bilateral synchronous lip adhesions with placement of a passive alveolar molding appliance at 4 to 8 weeks of age; definitive modified Manchester lip repair at 6 to 8 months of age; and a one-stage "two-flap" palatoplasty at 14 months of age. Neither gingivoperiosteoplasty nor early alveolar bone grafting was performed. Four patients required early surgical premaxillary setback because of adverse social reactions to a very protrusive premaxilla. All patients (7 to 9 years) were assessed prior to initiation of first-phase orthodontics (maxillary expansion) in anticipation of alveolar bone grafting. Cleft team records were reviewed to determine initial maxillary arch dysmorphology, treatment, and occlusal relationships in early mixed dentition stage. The initial maxillary dysmorphology was classified using a new grouping based on orientation of the vomer, the intercanine distance, and its symmetry. Patterns of mixed dentition occlusion were then compared with group type, and predication tables were generated. Because midface retrusion is the major dentoskeletal morbidity in cleft patients, angle Class I and II occlusions were designated as "favorable" and Class III as "unfavorable."

RESULTS

In early mixed dentition, approximately three-fourths of patients with complete BCLP had favorable occlusion and one-fourth unfavorable occlusion. The occlusal status seemed unrelated to the initial maxillary arch dysmorphology, the use of early passive alveolar molding appliance, or surgical premaxillary setback.

CONCLUSION

Patterns of variation within the initial dysmorphology of the maxillary arch in infants with complete BCLP cannot be used to predetermine subsequent molar occlusal relationships in the mixed dentition.

Routes of Ethephon Uptake in Pineapple (Ananas comosus) and Reasons for Failure of Flower Induction

Ethylene-releasing agents such as ethephon (2-chloroethylphosphonic acid) are used widely to induce flowering in pineapples (Ananas comosus (L.) Merrill). However, ethephon treatment is less reliable in summer, particularly if plants are treated on abnormally hot days. [(14)C]ethephon was used to follow uptake and translocation in leaf tissues. Up to 30% of the ethephon entered the leaf within 4 h, and up to 60% by 24 h. Uptake was dramatically modified by temperature, relative humidity, solution pH, and the surface on which solution droplets were placed. Entry occurred across the leaf cuticle and probably also by way of stomatal pores, and label was recovered at all depths within the leaf. (14)C label entered more rapidly through the abaxial epidermis than through the adaxial epidermis. Low-volume spray applications to whole plants resulted in rapidly drying droplets mainly on the adaxial, distal epidermis and were rather ineffective at inducing flowering, possibly because little ethephon or ethylene reaches the shoot apex. High-volume sprays may facilitate ethephon entry because solution accumulates in leaf axils and hence remains in prolonged contact with abaxial epidermis of leaf bases close to the shoot apex. When poured into the center of the plant, 20% of a normal commercial ethephon dose induced full flowering even under adverse temperatures. It is suggested that high-volume evening spraying and avoidance of hot days may reduce the incidence of flowering failure.

Growth, yield, and fruit quality of two non-astringent persimmon (Diospyros kaki) cultivars, Izu and Fuyu, in subtropical Australia

Growth, yield, and fruit quality of 2 non- astringent persimmon (Diospyros Inaki) cultivars, Izu and Fuyu, were evaluated under subtropical conditions of coastal Australia. Although maximum tree yields for Izu and Fuyu were high (24 and 37 t/ha, respectively) the percentage of fruit suitable for export was low and variable (range: Izu 8.547%; Fuyu 2844%). Main fruit quality defects were wind rub, petal adherance marks, fruitfly stings, calyx cavity, sunburn, and bird damage. Without fruit thinning, both cultivars were susceptible to overcropping in some seasons, which resulted in a high percentage (>40%) of small fruit (<150 g). Most fruit (80% for Izu and 90% Fuyu) had Brix levels higher than the recommended export standard of 14�.

Effects of girdling time on growth, yield, and fruit maturity of the low chill peach cultivar Flordaprince

Low chill Flordaprince peach trees in subtropical Australia were trunk-girdled at 1 of 3 times during fruit development: pre stone hardening (pre SH), post stone hardening (post SH), and 2 weeks before expected first harvest (BFH). Measures were made of fruit and shoot growth, harvest data, and starch levels in different tree parts. The pre SH girdling gave the greatest (P<0.05) increase in fruit size during stage 2 of fruit development, and pre and post SH girdling treatments gave progressively earlier (P<0.05) and shorter (10 days v. 24 days for control) main harvest period. Girdling resulted in greater numbers of fruit of larger, desirable marketable size (>90 g) than the control, although the latter caught up in average yield because of longer development period and some variability in numbers of fruit per tree. Split pip was not a problem. Fruit sugar content was significantly (P<0.05) higher with post SH and BFH girdling treatments than with control or pre SH treatment. Girdling temporarily increased starch levels in the leaves and shoots and reduced shoot growth.

Effects of hydrogen cyanamide, paclobutrazol and pruning date on dormancy release of the low chill peach cultivar Flordaprince in subtropical Australia

The growth regulator hydrogen cyanamide (Dormex, 50% a.i.) was tested for its effectiveness in promoting earlier and more even budbreak, flowering, and fruit maturity of the low chill peach cv. Flordaprince at 2 sites in subtropical Australia. The influence of the growth retardant paclobutrazol was also tested at 1 site, and at the other, the effect of altering pruning date. At 1 site only, hydrogen cyanamide applied early-mid June, during endodormancy, advanced mean harvest time by 10 days. At the other site, there were no consistent trends between harvest time and date of application of cyanamide. Dormex at the lowest concentration applied (10 mL/L) caused severe yield reductions (40.8%). Flowering and fruit maturity were advanced by about 6 days with dormant pruning in early winter, compared with pruning at later dates, and by 13 days with the application of the growth retardant paclobutrazol, compared with no application.