Outcomes of permanent canines on the cleft side after secondary alveolar grafting using different materials in complete unilateral cleft lip and palate.

The prevalence of impaction of the permanent canine on the cleft side (PCCS) ranges from 12-35% after alveolar bone grafting (ABG). PCCSs usually develop above other permanent teeth in the alveolar process, gradually becoming vertical until they reach the occlusal plane. The type of cleft, hypodontia of lateral incisor on the cleft side, slower PCCS root development, and genetic factors are predictors of impaction and/or its ectopic eruption. To compare the behavior of PCCS in individuals with complete unilateral cleft lip and palate (UCLP) subjected to secondary alveolar grafting (SAG) with different materials. This retrospective longitudinal study analyzed 120 individuals undergoing SAG with iliac crest bone, rhBMP-2, and mandibular symphysis. The individuals were selected at a single center and equally divided into three groups. Panoramic radiographs were analyzed by the Dolphin Imaging 11.95 software to measure PCCS angulation and PCCS height from the occlusal plane at two different timepoints. No statistical significance was found between grafting materials (P=0.416). At T1, the PCCS height from the occlusal plane was greater for rhBMP-2 and mandibular symphysis compared to iliac crest bone. The lateral incisor on the cleft side was not related to success or lack of eruption of PCCS (P=0.870). Impaction rates of PCCS were similar for the materials studied. Absence of the lateral incisor on the cleft side did not prevent spontaneous eruption of PCCSs.

Evaluation of Radiographic Outcomes of Alveolar Graft Associated with Premaxillary Osteotomy Performed with rhBMP-2.

OBJECTIVE: To evaluate the influence of filling material and timing of surgery on radiograph outcomes of alveolar grafting with premaxillary osteotomy. The null hypothesis was that radiographic outcomes would be similar with both rhBMP-2 (rhBMP-2G) and cancellous bone from the iliac crest (IG), regardless of the timing of surgery. DESIGN: Cross-sectional study with consecutive sampling of 56 periapical or occlusal radiographs taken 12 months after surgery. SETTING: A single tertiary craniofacial center. PATIENTS/PARTICIPANTS: Twenty-eight patients with complete bilateral cleft lip and palate and mean age of 13 years. The individuals underwent bilateral alveolar grafting associated with premaxillary osteotomy (AG + PO) with rhBMP-2 or cancellous bone from the iliac crest. INTERVENTIONS: Experienced maxillofacial surgeons used the same surgical technique in both groups. AG + PO were assigned as success or failure by 3 blinded raters based on modified Bergland and SWAG scales. MAIN OUTCOME MEASURES: The influence of filling materials and timing of surgery on radiographic outcomes was verified by Fisher's exact test and chi-square test (P < .05). RESULTS: There was no significance variation between the mean age of participants in the rhBMP-2G and IG (P = .471). Scales showed almost perfect reliability (agreement rate = 96.4%; K = 0.85). rhBMP-2G and IG had similar success rates with modified Bergland scale (85.7% and 82.1%) and SWAG scale (92.9% and 82.1%), respectively. However, only modified Bergland scale found influence of age on radiographic outcomes (P = .025). CONCLUSIONS: AG + PO performed with rhBMP-2 and iliac crest bone showed similar radiographic success rates, regardless of the timing of surgery.

Outcomes of permanent canines on the cleft side after secondary alveolar grafting using different materials in complete unilateral cleft lip and palate

Abstract The prevalence of impaction of the permanent canine on the cleft side (PCCS) ranges from 12-35% after alveolar bone grafting (ABG). PCCSs usually develop above other permanent teeth in the alveolar process, gradually becoming vertical until they reach the occlusal plane. The type of cleft, hypodontia of lateral incisor on the cleft side, slower PCCS root development, and genetic factors are predictors of impaction and/or its ectopic eruption. Objective: To compare the behavior of PCCS in individuals with complete unilateral cleft lip and palate (UCLP) subjected to secondary alveolar grafting (SAG) with different materials. Methodology: This retrospective longitudinal study analyzed 120 individuals undergoing SAG with iliac crest bone, rhBMP-2, and mandibular symphysis. The individuals were selected at a single center and equally divided into three groups. Panoramic radiographs were analyzed by the Dolphin Imaging 11.95 software to measure PCCS angulation and PCCS height from the occlusal plane at two different timepoints. Results: No statistical significance was found between grafting materials (P=0.416). At T1, the PCCS height from the occlusal plane was greater for rhBMP-2 and mandibular symphysis compared to iliac crest bone. The lateral incisor on the cleft side was not related to success or lack of eruption of PCCS (P=0.870). Conclusion: Impaction rates of PCCS were similar for the materials studied. Absence of the lateral incisor on the cleft side did not prevent spontaneous eruption of PCCSs.

Influence of bone-anchored maxillary protraction on secondary alveolar bone graft status in unilateral complete cleft lip and palate.

INTRODUCTION: Our objective was to evaluate the effects of bone-anchored maxillary protraction (BAMP) on the status of the secondary alveolar bone graft in patients with unilateral complete cleft lip and palate (UCLP). METHODS: The experimental group (EG) comprised 26 patients with UCLP, mean age of 11.9 years, submitted to secondary alveolar bone grafting (SABG) with recombinant bone morphogenetic protein, and BAMP therapy, using miniplate-borne Class III intermaxillary elastics. Cone beam computed tomography (CBCT) examinations were taken 6 months after SABG and before BAMP (T1) and after 18 months of BAMP therapy (T2). The control group (CG) was composed of 24 patients with UCLP submitted only to SABG with recombinant bone morphogenetic protein or autogenous bone from iliac crest without BAMP therapy, matched by initial age and sex with the EG. In the CG, CBCT examinations were performed 6 months (T1) and 12 months (T2) after SABG surgery. CBCT axial sections were analyzed using Garib scores in both time points. Intra- and intergroup comparisons were performed using Wilcoxon and Mann-Whitney tests, respectively (P <0.05). RESULTS: No intergroup differences were found at T1 and T2. The EG showed significant improvement of graft status from T1 to T2 at the cervical and middle levels of the alveolar cleft. No significant interphase differences were found for graft scores in the CG. CONCLUSIONS: Despite loads of intermaxillary elastics applied to the maxilla, no harm to the grafted alveolar bone was observed after BAMP therapy in patients with UCLP.

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.

Evaluation of secondary alveolar bone grafting outcomes performed after canine eruption in complete unilateral cleft lip and palate.

OBJECTIVES: Evaluate the results of secondary alveolar bone grafting (SABG) in patients with complete unilateral cleft lip and palate (UCLP), operated after permanent canine eruption (CE). MATERIALS AND METHODS: Seventy-four periapical radiographs from patients with complete UCLP (mean age 14 years) submitted to SABG were retrospectively analyzed for the amount of bone in the cleft site through the Bergland and Chelsea scales. RESULTS: Of the cases, 47.3 % was classified as Bergland type I and Chelsea type A, 35.2 % as type II/C, 6.7 % as type III/D, and 10.8 % as type IV/failure. When the canine was moved into the grafted area, the success rate (type I/A) was 56.8 %; for cases in which the space was maintained for an implant or prosthetic finishing, the index was 45.8 %; however, this difference was not statistically significant. CONCLUSION: Even in advanced ages, after permanent canine eruption, SABG can be considered a highly successful procedure. CLINICAL RELEVANCE: This research shows good results of secondary alveolar bone grafting performed in patients with unilateral complete cleft lip and palate, even when it was performed after eruption of the permanent canine in the cleft area.

Evolution of Postoperative Edema in Alveolar Graft Performed With Bone Morphogenetic Protein (rhBMP-2).

OBJECTIVE: To evaluate the evolution of facial edema in the postoperative period after alveolar graft surgeries performed with collagen membrane soaked with recombinant human bone morphogenetic protein-2 (rhBMP-2) in individuals with cleft lip and palate. DESIGN: Longitudinal prospective. SETTING: Tertiary craniofacial center. PARTICIPANTS: One hundred fifty individuals submitted to alveolar graft. INTERVENTIONS: In the preoperative consultation and 4 days after surgery, the individuals were assessed as to age, professional performing the surgery, duration of the procedure, type of cleft, measurement of facial edema, mouth opening, and global evaluation of the postoperative period. MAIN OUTCOME MEASURES: Statistical analysis was performed to compare the facial edema and different variables, at a significance level of .05. RESULTS: The maximum facial edema occurred between 3 and 4 days postoperatively, was inversely proportional to age and mouth opening, greater for female patients compared with male patients, for incomplete unilateral cleft lip and palate compared with other types of clefts, and for surgeon 1 compared with the other surgeons at some moment postoperatively. The surgeries were longer for complete unilateral and bilateral clefts. The difference was statistically significant for these variables. CONCLUSIONS: The facial edema was influenced by the rhBMP-2 used in alveolar graft, and trismus was proportional to the intensity of facial edema.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC-USP) - part 3: Oral and Maxillofacial Surgery

This paper presents the treatment protocol of maxillofacial surgery in the rehabilitation process of cleft lip and palate patients adopted at HRAC-USP. Maxillofacial surgeons are responsible for the accomplishment of two main procedures, alveolar bone graft surgery and orthognathic surgery. The primary objective of alveolar bone graft is to provide bone tissue for the cleft site and then allow orthodontic movements for the establishment of an an adequate occlusion. When performed before the eruption of the maxillary permanent canine, it presents high rates of success. Orthognathic surgery aims at correcting maxillomandibular discrepancies, especially anteroposterior maxillary deficiencies, commonly observed in cleft lip and palate patients, for the achievement of a functional occlusion combined with a balanced face.

Timing of alveolar bone grafting determines different outcomes in patients with unilateral cleft palate.

The objective of the current study was to assess the outcome of the alveolar bone grafting (ABG) in patients with cleft palate. Thirty-one patients with complete unilateral cleft lip and palate were prospectively divided into 2 groups according to the timing of surgery: (1) secondary ABG (SABG), undertaken during mixed dentition (n = 16); and (2) tertiary ABG (TABG), undertaken during permanent dentition (n = 15). Septum height was assessed using cone beam computed tomography in 3 views (buccal, intermediate, palatal) and classified according to the modified Bergland Index, which scores the results into 5 types according to the height of the neoformed bone septum (excellent: septum with a normal height; good: septum with minor deficiency; regular: marginal defect of >25% of the root length; bad: bone deficiency on the nasal aspect; and failure). In the SABG group, 6 to 12 months postoperatively, 75% of the patients were classified as having excellent/good conditions and 25% as having regular/bad conditions. No patients were observed as having failure conditions. In the TABG group, 53% of the patients were classified as having excellent/good, 21% were classified as having regular/bad conditions, and 26% were classified as having failure conditions. Significantly better outcomes were observed for the SABG group when compared with the TABG group. In conclusion, the age at which ABG is performed is a factor that impacts on the surgical outcome. Specifically, increasing age is associated with worse outcomes.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies-USP (HRAC-USP)--part 3: oral and maxillofacial surgery.

This paper presents the treatment protocol of maxillofacial surgery in the rehabilitation process of cleft lip and palate patients adopted at HRAC-USP. Maxillofacial surgeons are responsible for the accomplishment of two main procedures, alveolar bone graft surgery and orthognathic surgery. The primary objective of alveolar bone graft is to provide bone tissue for the cleft site and then allow orthodontic movements for the establishment of an an adequate occlusion. When performed before the eruption of the maxillary permanent canine, it presents high rates of success. Orthognathic surgery aims at correcting maxillomandibular discrepancies, especially anteroposterior maxillary deficiencies, commonly observed in cleft lip and palate patients, for the achievement of a functional occlusion combined with a balanced face.

Influence of enamel matrix derivative (Emdogain) and sodium fluoride on the healing process in delayed tooth replantation: histologic and histometric analysis in rats.

Although it has already been shown that enamel matrix derivative (Emdogain) promotes periodontal regeneration in the treatment of intrabony periodontal defects, there is little information concerning its regenerative capacity in cases of delayed tooth replantation. To evaluate the alterations in the periodontal healing of replanted teeth after use of Emdogain, the central incisors of 24 Wistar rats (Rattus norvegicus albinus) were extracted and left on the bench for 6 h. Thereafter, the dental papilla and the enamel organ of each tooth were sectioned for pulp removal by a retrograde way and the canal was irrigated with 1% sodium hypochlorite. The teeth were assigned to two groups: in group I, root surface was treated with 1% sodium hypochlorite for 10 min (changing the solution every 5 min), rinsed with saline for 10 min and immersed in 2% acidulated-phosphate sodium fluoride for 10 min; in group II, root surfaces were treated in the same way as described above, except for the application of Emdogain instead of sodium fluoride. The teeth were filled with calcium hydroxide (in group II right before Emdogain was applied) and replanted. All animals received antibiotic therapy. The rats were killed by anesthetic overdose 10 and 60 days after replantation. The pieces containing the replanted teeth were removed, fixated, decalcified and paraffin-embedded. Semi-serial 6-microm-thick sections were obtained and stained with hematoxylin and eosin for histologic and histometric analyses. The use of 2% acidulated-phosphate sodium fluoride provided more areas of replacement resorption. The use of Emdogain resulted in more areas of ankylosis and was therefore not able to avoid dentoalveolar ankylosis. It may be concluded that neither 2% acidulated-phosphate sodium fluoride nor Emdogain were able to prevent root resorption in delayed tooth replantation in rats.

The use of negative pressure for the sinus lift procedure: a technical note.

The objective of the present report was to present a modification of the standard sinus lift procedure. The modification consists of the creation of a mechanism facilitating maxillary sinus mucosa lift by means of negative pressure and simplification of the instrumentation used for this procedure. With the change in technique, maintenance of the success and predictability rates observed in the literature is possible.

Função canino desempenhada pelo pré-molar / Canine function performed by the premolar

A extração do canino permanente suscita indignação de muitos ortodontistas ortodoxos cuja opinião oscila da ambivalência à condenação radical, devido principalmente à crença do perverso déficit funcional resultante, mas também atrelada à preocupação do efeito estético no sorriso. Essa última, sim, preocupação maior do leigo, que vê a Ortodontia principalmente como um exercício estético. Sem trair as convicções certamente legítimas, os objetivos oclusais de um tratamento ortodôntico visam conciliar estética, função e saúde periodontal, com ou sem caninos. O presente artigo ilustra a possibilidade de trocar o canino pelo primeiro pré-molar num tratamento ortodôntico conduzido com extração de dentes. Essa situação, que enfrenta resistência por parte de ambos, ortodontistas e pacientes, elimina o dente canino sem, no entanto, eliminar a função da cúspide canina na desoclusão lateral, isolada ou em grupo, o que sela harmonia com os conceitos funcionais da escola gnatológica.

Anquilose intencional de caninos decíduos: reforço de ancoragem para a tração reversa da maxila / Intentional ankylosis of primary canines: anchorage to potentialize the maxillary protraction

O presente artigo descreve a obtenção da anquilose intencional dos caninos decíduos e exemplifica a sua aplicação como ancoragem para potencializar o efeito ortopédico da tração reversa da maxila na má oclusão de Classe III

A cirurgia ortognática na reabilitaçäo do paciente portador de fissura unilateral completa de lábio e palato / Orthognatic surgery in the rehabilitation of a complete unilateral cleft lip and palate patient

Definidas como a falta de coalescências entre os processos faciais embrionários e entre os processos palatinos, as fissuras lábio-palatais representam um desafio à integraçäo social de seu portador, pois, quando acometem o lábio, estampam na face suas marcas inexoráveis e, quando acometem apenas o palato, deixam suas sequelas no mais importante processo da comunicaçäo: a fala. O processo de reabilitaçäo das fissuras lábio-palatais é complexo e lento, portanto, deve ser formulado com prudência e coerência. A sequência terapêutica tem início bem cedo, nos primeiros anos e meses de vida, com as cirurgias primárias do lábio e palato. Nas fissuras completas de lábio e palato, essas cirurgias passam a exercer um papel negativo sobre a face média, impedindo-a de alcançar a plenitude do seu potencial genético de crescimento. `A ortodontia cabe a supervisäo do crescimento facial durante o desenvolvimento da oclusäo, com o objetivo de reduzir o défict maxilar a partir do final da dentadura decídua e do qual a ortopedia maxilar precoce, pré e pós-cirurgias primárias, é excluída. Este artigo se refere à reabilitaçäo facial e oclusal de um paciente portador de uma fissura unilateral completa de lábio e palato, através da interaçäo ortodontia/cirurgia ortognática/cirurgia plástica. Na realidade, o tratamento aqui apresentado representa apenas um dos pilares do longo processo reabilitador, que deve sempre incluir, entre outras especialidades, a fonoaudiologia, para que a reabilitaçäo seja completa e consiga reintegrar o indivíduo no seu universo social