Incidence of complications in secondary alveolar bone grafting of bilateral clefts with premaxillary osteotomy: a retrospective cohort study.

OBJECTIVE: To evaluate factors affecting incidence of complications after secondary alveolar bone grafting with premaxillary osteotomy (SABG + PO) in children with complete bilateral cleft of lip and palate (BCLP). MATERIALS AND METHODS: Data were collected from children with BCLP treated with SABG + PO from 2004 to 2014 at our institute. Preoperative parameters included age, donor site, race, gingival health, bone quality around cleft-related teeth, premaxilla position, graft timing, presence of canines in the cleft, and presence of deciduous teeth around the cleft area. Logistic regression and the chi-squared test were used to assess correlations and the incidence of complications. RESULTS: In the 64 patients, a significant correlation was found between complication rate and timing of bone grafting with respect to early versus late SABG + PO (p = 0.041), age > 12 years (p = 0.011; odds ratio (OR) 5.9; 95% confidence interval (CI) 1.49-23.93), malposition of the premaxilla (p = 0.042; OR 3.3; 95% CI 1.04-10.13), and preoperative bone quality around cleft-related teeth (p = 0.005; OR 5.3; 95% CI 1.6-17.2). CONCLUSIONS: The timing of SABG + PO is essential, as early SABG + PO is associated with fewer complications. A malpositioned premaxilla and poor bone quality around cleft-related teeth are associated with more complications. Therefore, preoperative orthodontic repositioning of the malpositioned premaxilla before SABG + PO should be considered. CLINICAL RELEVANCE: Analysis of treatment protocols and complications for BCLP patients underscores that proper timing of SABG + PO and correct premaxilla repositioning help reduce complications.

Quality of Life and Patient Satisfaction in Adults Treated for a Cleft Lip and Palate: A Qualitative Analysis.

OBJECTIVE: Long-term outcomes of patients born with a cleft lip and palate (CLP) are scarcely investigated. Yet, this patient group is of particular interest, as they can provide a valuable retrospective view upon their treatment experiences and psychological adjustment. Qualitative accounts may be especially useful in understanding the patient journey. DESIGN: The present study set out to evaluate quality of life and satisfaction with treatment in adult patients previously treated for CLP at the Wilhelmina Children's Hospital. Semistructured interviews were performed. PATIENTS: A total of 22 patients aged 17 to 35 years (mean: 25 years) were interviewed about their experiences of growing up with CLP and of the treatment they received. Interviews were audio-recorded and factors thought to influence psychological adjustment were identified. RESULTS: Four main themes were identified: background factors, support systems, treatment factors, and coping/internal factors. Each theme was described with illustrative quotes. CONCLUSION: This study underlines that psychological adjustment can fluctuate over time and greatly differs between individuals, even during adulthood. Psychological support should therefore be available beyond the finalization of the treatment course. Furthermore, the majority of participants stated they had wanted more psychological support as a child to facilitate resilience and to help them cope with challenges.

Midfacial growth and dental arch relationships in bilateral cleft palate following secondary alveolar bone grafting and orthodontic intervention: Factors predicting a Le Fort I osteotomy at age 18.

OBJECTIVE: To evaluate midfacial growth and dental arch relationships in patients treated for bilateral cleft lip and palate (BCLP). MATERIALS AND METHODS: Data were collected from all patients with BCLP treated at our hospital between 2004 and 2014, with or without premaxillary osteotomy (PO). Dental casts for pre-secondary alveolar bone grafting with PO (SABG + PO) and end-point dental casts were analyzed using the BAURU yardstick scoring system. Pre-SABG + PO, post-SABG + PO, and end-point SABG + PO lateral cephalograms were analyzed. The correlation between both scoring systems was calculated. RESULTS: There were no significant differences between the BAURU scores for centers in a previous study and those collected here. A negative correlation was found between the pre-SABG + PO ANB (Angle between A-point, Nasion and B-point) angle and pre-SABG + PO BAURU scores (R = -0.58; p = 0.000), the long-term post-SABG + PO ANB and mean end-point BAURU (R = -0.50; p = 0.000), and the pre-SABG + PO ANB and mean end-point BAURU (R = -0.51; p = 0.000). CONCLUSION: We found no significant difference between pre-SABG + PO and end-point BAURU scores. There was a decrease in the SNA (Angle between Sella, Nasion and A-point) and ANB angle over time, indicating delayed growth of the maxilla. We found a negative correlation between the pre-SABG ANB and end-point BAURU scores. Pre-SABG ANB can be used to predict the need for Le Fort I osteotomy at age 18.

Taking the endochondral route to craniomaxillofacial bone regeneration: A logical approach?

The current golden standard for treatment of craniomaxillofacial critical size bone defects, autologous bone grafting, is associated with several disadvantages which have prompted an increased demand for alternatives. New solutions are emerging in the form of bone tissue engineering. This involves harvesting of multipotent mesenchymal stromal cells (MSCs), after which they can be differentiated towards the osteogenic lineage mimicking intramembranous bone formation. However, translating this approach from laboratory to clinic has met with limited success. Consequently, attention has shifted towards investigation of the alternative endochondral route of bone regeneration. At a first glance, this approach may not appear logical for maxillofacial bone regeneration as most bones in the face originate from intramembranous mechanisms. Therefore, the goal of this review is to discuss the sense and non-sense of exploring endochondral bone regeneration as a novel reconstructive option for craniomaxillofacial bone defects. The embryological origin of craniomaxillofacial bone structures and their repair mechanisms are introduced. Also, the potential of MSC-like cells, the neural crest-derived stem cells from craniomaxillofacial sources, are discussed with a focus on regeneration of bone defects. Further, the current status of endochondral bone regeneration from MSCs is highlighted. Together, these aspects contribute in answering whether endochondral bone regeneration can be a logical approach to restore craniomaxillofacial bone defects.

A novel semi-automatic segmentation protocol for volumetric assessment of alveolar cleft grafting procedures.

A novel protocol for volumetric assessment of alveolar cleft grafting procedures is presented. Eleven cone-beam computed tomography (CBCT) datasets of patients who underwent secondary alveolar cleft reconstructive surgery for a unilateral alveolar cleft were evaluated by two investigators. Residual bone volumes 1 year after surgery were analysed using a semi-automated technique in which preoperative CBCT datasets were superimposed on the postoperative scans using voxel-based registration. To define the correct boundaries of the alveolar cleft defect in the preoperative CBCT dataset, a mirror image of the preoperative CBCT dataset was superimposed on the preoperative CBCT dataset. For the difference in residual bone volume between the two observers, an intraclass correlation of 0.98 and a Dice coefficient of 0.89 were found. This study describes a reliable segmentation protocol for volumetric analysis of the alveolar cleft defect in patients with a unilateral alveolar cleft.

Long-Term Results of Mandibular Distraction Osteogenesis with a Resorbable Device in Infants with Robin Sequence: Effects on Developing Molars and Mandibular Growth.

BACKGROUND: Mandibular distraction osteogenesis with a unidirectional resorbable device is an effective treatment option for severe upper airway obstruction in infants with Robin sequence. Long-term effects, especially with regard to tooth development and mandibular outgrowth, are not known. METHODS: Robin sequence infants with a follow-up of greater than or equal to 5 years were included. Baseline characteristics were extracted from medical records. Panoramic and lateral cephalometric radiographs were analyzed and patients were recalled for physical examination. RESULTS: Ten infants underwent mandibular distraction osteogenesis at a mean age of 3.7 months (median, 19 months; range, 11 days to 27 months). Mean length of follow-up was 6.8 years (range, 5.0 to 7.9 years). Ten Robin sequence infants without mandibular distraction osteogenesis (mean length of follow-up, 7.4 years; range, 6.7 to 8.9 years) were the controls. Shape anomalies, positional changes, and root malformations of molars were seen significantly more often than in the control group (p = 0.007, p = 0.009, and p = 0.043, respectively). Mandibular length was shorter (p = 0.030), but mandibular ramus height was comparable (p = 0.838) with that of the non-mandibular distraction osteogenesis group. Compared with healthy controls, all Robin sequence infants had a significantly shorter mandible. CONCLUSIONS: Mandibular distraction osteogenesis with a resorbable system reveals overall good short- and long-term results, but the effects on developing molars and mandibular outgrowth likely necessitate secondary procedures. This factor should be considered when deciding on treatment options and counseling of parents. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Management of the premaxilla in the treatment of bilateral cleft of lip and palate: what can the literature tell us?

OBJECTIVE: In the treatment of bilateral cleft lip and palate (BCLP) patients, there is discussion about the management of the position of the premaxilla. This literature analysis summarises the literature on managing this condition. MATERIALS AND METHODS: A PubMed, Embase and Cochrane Library search was conducted resulting in 4465 articles which were screened on title and abstract. RESULTS: Seventy-one articles were available in full text, 16 of which were included in this literature analysis. We searched on keywords timing and technique, complications, growth of the maxilla and results after bone grafting the alveolar process. This literature analysis has shown that there are various ways to correct the position of the premaxilla. These can be divided into primary, early, late secondary and tertiary intervention before the age of 8 years, between the ages of 8 and 12 years and older than 12 years. Correction is done with surgery, orthodontics or a combination, with or without bone grafting. CONCLUSIONS: An osteotomy of the premaxilla in combination with secondary alveolar bone grafting appears to be the most successful technique. Combining early secondary alveolar bone grafting with osteotomy creates more room to ensure a watertight closure of the nasal mucosa resulting in fewer postoperative complications. Before surgery, the orthodontist should try to optimise the position of the premaxilla for its surgical correction prior to bone grafting. CLINICAL RELEVANCE: The treatment of BCLP patients is still based on experience and expert opinions. This literature analysis tries to give a summery on how to handle the protruded and displaced premaxilla.

Does a change in bone mineral density occur in the mandible of Göttingen minipigs after irradiation in correlation with radiation dose and implant surgery?

PURPOSE: To date, studies have not agreed on the effects of irradiation on bone mineral density. The aim of our study was to investigate the changes in mandibular bone mineral density after irradiation at various doses with and without surgery. MATERIALS AND METHODS: We implemented a descriptive animal experiment. The sample included 16 female Göttingen Minipigs, randomly assigned to 4 groups and irradiated with equivalent doses of 0, 25, 50, and 70 Gy to the mandibular region. At 3 months after irradiation, the mandibular left premolars and molars were removed, and dental implants were placed. Computed tomography scans were taken before and 6 months after irradiation. The measured bone density was related to a bone phantom to calculate the bone mineral density quotient (BMDQ). The outcome variable was the BMDQ. Other study variables were the radiation dose and surgery. Descriptive and univariate analyses were computed, and significance was set at P ≤ .05. RESULTS: In the left hemimandible, compared with the control group, a significant decrease in BMDQ was observed: 0.01 at 0 Gy, -0.01 at 25 Gy, -0.06 at 50 Gy, and -0.11 at 70 Gy (P = .023). The right hemimandible compared with the control group also showed a significant decrease in BMDQ: -0.02 at 0 Gy, -0.08 at 25 Gy, -0.09 at 50 Gy, and -0.11 at 70 Gy (P = .007). CONCLUSIONS: The present study used a large animal model to simulate the tissue reactions induced by various radiation doses in the mandible. We found a significant decrease in the BMDQ after irradiation, but no significant correlation could be found between the irradiation dose and a decrease in the BMDQ.