Retrospective analysis of clinical outcomes in bilateral cleft lip and palate patients after secondary alveolar bone grafting and premaxilla osteotomy, using a new dento-maxillary scoring system.

Evaluation of relevant clinical outcomes in patients with bilateral cleft lip and palate (BCLP) after secondary aveolar bone grafting (SABG) and premaxilla osteotomy (PMO), through the use of a new scoring system. Data were collected retrospectively from all patients with BCLP who were operated on between 2004 and 2014, at the end of follow-up. The treatment protocol consisted of SABG + PMO in patients aged between 9 and 13 years. At the end of follow-up, the following parameters were scored: (un)interrupted dental arch, skeletal sagittal relationship, bone height using the Bergland/Abyholm criteria, and the presence of postoperative fistula. These parameters were combined to produce a dento-maxillary scoring system, giving a final score between 1 and 10. For statistical analysis, the independent t-test was used. Of 55 children, 45 were suitable for analysis. The mean age at time of surgery was 12.0 years (8.9-16.4 yrs), and the mean follow-up time was 11.7 years (5.8-15.8 yrs). The average number of surgeries executed under general anesthesia was 6 (range: 3-11). The average dento-maxillary score in this patient cohort was 7.6 (1-10; median: 8). Among these patients, 31 had an uninterrupted dental arch; the average Bergland/Abyholm score was 2.07; 30 patients exhibited an Angle class I incisor relationship; and, in 38 cases, the oronasal communication was closed after SABG + PMO treatment. A significant effect of fistulas was seen on dento-maxillary score (p = 0.001). Specifically, a significant effect of fistulas was seen on interrupted dental arch (p = 0.002) and on Bergland/Abyholm score (p = 0.037). The proposed dento-maxillary scoring system is a straightforward tool that can be used to describe and analyze the amount of dento-maxillary rehabilitation at the end of the treatment. Persistence of oronasal fistulas in patients with BCLP has a significant impact on interruption of the dental arch, and can influence dental results at the end of the second decade.

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.

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.

Microstructured ß-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 (ß-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 ß-TCP putty at the other. After 24 weeks of implantation, histomorphometric and micro-computer tomography analyses proved that the ß-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 ß-TCP putty in the reconstruction of the alveolar cleft and other challenging two-wall bony defects.