Bone-anchored maxillary protraction in a patient with complete cleft lip and palate: A case report.

Sagittal maxillary deficiency is frequently observed in patients with operated unilateral complete cleft of the lip and palate. Treatment for moderate to severe Class III malocclusion usually relies on LeFort I surgery for maxillary advancement after the end of growth. This case report describes bone-anchored maxillary protraction in a 10-year-old white boy with unilateral complete cleft of the lip and palate. His interarch relationship was diagnosed as GOSLON index 5 before treatment with a negative overjet of 3.2 mm. The orthopedic traction was started 4 months after secondary alveolar bone graft surgery and before comprehensive orthodontic treatment. Class III elastics were used full time for 18 months. After treatment, the interarch relationship was GOSLON index 1 with a positive overjet. The SNA angle increased by 6.50° and A-Na Perp increased by 3.8 mm, leading to marked improvement in facial convexity (+14.6°). No posterior rotation of the mandible occurred with a slight closure of the gonial angle. Visualization of 3-dimensional color-coded maps showed an overall forward maxillary displacement. The bone-anchored maxillary protraction results for this patient are a promising orthopedic therapy for patients with unilateral complete cleft of the lip and palate, with the advantage of achieving much earlier improvement of facial esthetics and functional occlusion, compared with LeFort I surgery at skeletal maturity.

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.

Influence analysis of cleft type and supernumerary teeth eruption in the prognosis of bone graft in patients with cleft palate.

OBJECTIVE: The aim of this study was to investigate the influence of cleft type and supernumerary tooth eruption on the treatment of palatal clefts with alveolar bone grafts. MATERIALS AND METHODS: In this article, medical records of 40 patients with palatal clefts and associated supernumerary teeth who were treated with alveolar bone grafting in the Hospital for Craniofacial Anomalies Rehabilitation were assessed. The patients were studied to assess the influence of supernumerary teeth and the cleft severity on the prognosis of the alveolar bone graft. RESULTS: Forty medical records were included in the assessment. When the teeth in the cleft had an anatomic shape close to canine, we called them precanine. When they were very small or malformed, we called them anomalous lateral incisors. The teeth studied showed good prognoses and were more expressive in the preforaminal clefts (87.5%) than in the transforaminal ones (62.5%). Moreover, the transforaminal clefts presented a higher percentage in satisfactory and poor prognoses (37.5%). The authors found that supernumerary teeth influenced the maintenance of alveolar bone graft height and that transforaminal clefts presented a worse prognosis than preforaminal clefts.

Increase in age is associated with worse outcomes in alveolar bone grafting in patients with bilateral complete cleft palate.

This prospective study aimed at evaluating the surgical outcomes of alveolar bone grafting (ABG) in subjects with bilateral cleft lip and palate treated at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, Brazil, by means of cone-beam computed tomography. Twenty-five patients with bilateral complete cleft lip and palate, resulting in 50 clefts, were analyzed. Subjects were divided into 2 groups according to the dentition status at the time of surgery: (1) SABG group: subjects with mixed dentition operated on before or immediately after eruption of the permanent canine (10-13 years); (2) TABG group: subjects with permanent dentition (15-23 years). Cone-beam computed tomography analysis was performed in the buccal, intermediate, and palatal views, 2 and 6 to 12 months postoperatively. In the SABG group, 96% of the grafts were classified as successful, and no failure cases were observed. In the TABG group, successful cases decreased to 65%, and failures were seen in 27% of the cleft sites. In both postoperative periods, significantly better outcomes (lower mean scores) were observed for the SABG group in all the cone-beam computed tomography views (P < 0.05). Results show that the timing of surgery is an important factor in determining the outcomes of ABG in patients with bilateral cleft lip and palate, with increasing age being associated with the worse outcomes.

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.