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Introduction: Cleft alveolar bone graft surgery is technically challenging to perform as well as difficult to learn and teach. A high-fidelity cleft alveolar bone graft simulator was previously developed. However, further evaluation of the simulator is necessary to assess its efficacy., Methods: Two cleft simulation workshops were conducted in which participants were led through a simulated cleft alveolar bone graft. The first simulation workshop involved six plastic surgery trainees. The second workshop involved 43 practicing cleft surgeons. The participants were provided with a Likert-type questionnaire assessing the simulators' features, realism, and value as a training tool. The change in self-reported confidence was assessed by providing each participant with a pre- and post-simulation confidence questionnaire., Results: There was overall agreement in the realism of the simulators' features (average score of 4.67 and 3.80 out of 5 for the trainees and surgeons, respectively). There was overall agreement to strong agreement in the simulators value as a training tool (average score of 5 and 4.43 out of 5 for the trainees and surgeons, respectively). The self-reported confidence increased for all questionnaire items for both the trainees and surgeons. This was significant (p < 0.05) for five out of eight and all questionnaire items for the trainees and surgeons, respectively. The magnitude of the confidence increase was generally greater for less experienced participants., Conclusion: The cleft alveolar bone graft simulator was found to be realistic and valuable as a training platform. Use of the simulator improved self-reported confidence in cleft alveolar bone graft surgery., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.)

Background: To enhance the success rate of alveolar bone grafting, it is crucial to identify the factors that may influence the postoperative bone formation. This study aimed to investigate the impact of various osseous structure characteristics of alveolar clefts on the survival ratio of autogenous cancellous bone particle grafts., Methods: A retrospective study was conducted on 60 patients who underwent surgery performed by the same surgeon between 2016 and 2022. Two researchers measured and recorded the bone defect volume (DV), postoperative bone formation volume at 1 year, contact area between the graft and the bone surface within the cleft (S), cleft width (CW), osseous occlusion relationships, and presence of a cleft palate and initial bone bridge within the cleft for each patient. Pearson correlation analysis, Spearman's correlation analysis, and multiple linear regression analysis were performed., Results: The analysis results revealed statistical correlations between DV, CW, ratio of S to DV, cleft palate, initial bone bridge presence, and occlusion relationships with the survival rate. Multiple linear regression analysis showed that initial bone bridge and occlusion relationships affected the graft survival rate., Conclusions: Based on the presence of initial bone bridges and occlusions, we can make a rough estimate of the postoperative bone formation outcome in patients. However, the underlying mechanisms by which these two factors influence the bone formation require further investigation. In addition, preoperative orthodontic treatment to improve occlusal relationships may improve the postoperative bone formation outcomes in alveolar bone grafting., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Although childhood obesity matters, the association between body mass index (BMI) and bone mineral density (BMD) progression in grafted tissue after secondary alveolar bone grafting (ABG) for children with cleft alveolus is scarcely studied. Accordingly, this study explored the influence of BMI on BMD progression after ABG., Methods: In total, 39 patients with cleft alveolus receiving ABG at the mixed dentition stage were enrolled. Patients were classified as underweight, normal weight, or overweight or obese according to age- and sex-adjusted BMI. BMD was measured in Hounsfield units (HU) from cone-beam computed tomography scans obtained 6 months (T1) and 2 years (T2) postoperatively. Adjusted BMD (HU grafted tissue /HU pogonion , BMD a ) was used for further analysis., Results: For underweight, normal-weight, and overweight or obese patients, BMD aT1 values were 72.87%, 91.85%, and 92.89%, respectively (p = 0.727); BMD aT2 values were 111.49%, 112.57%, and 113.10% (p = 0.828); and density enhancement rates were 29.24%, 24.61%, and 22.14% (p = 0.936). No significant correlation was observed between BMI and BMD aT1 , BMD aT2 , or density enhancement rates (p = 0.223, 0.156, and 0.972, respectively). For patients with BMI < 17 and ≥ 17 kg/m 2 , BMD aT1 values were 89.80% and 92.89%, respectively (p = 0.496); BMD aT2 values were 111.49% and 113.10% (p = 0.216); and density enhancement rates were 23.06% and 26.39% (p = 0.573)., Conclusion: Patients with different BMI values had similar outcomes (BMD aT1 , BMD aT2 , or density enhancement rate) after our ABG procedure in the 2-year postoperative follow-up., Competing Interests: Conflict of interest The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Alveolar cleft reconstruction is important to increase the quality of life of cleft lip and palate patients. Usually, alveolar clefts can be reconstructed using bone grafts. However, bone grafting can be insufficient, and other alternatives may be necessary in wide and recalcitrant clefts. The medial femoral condyle (MFC) flap may be the solution for alveolar clefts that are impossible to reconstruct with bone grafting. In this study, the reconstruction of alveolar clefts in the pediatric cleft lip and palate population, using the MFC flap, is described. This study examined 9 pediatric patients whose alveolar clefts were reconstructed prospectively using MFC flap in 2015 and 2019. The age, gender, follow-up times, independent parameters, and existence of concomitant vestibulonasal fistulas of the patients were recorded. Computerized tomography images of the patients were evaluated to detect defect characteristics and evaluate the volume of flap postoperatively. Flap viability was confirmed with bone scintigraphy, and donor area morbidity was evaluated with the Dynamic Gait Index (DGI) in the postoperative period. The study included 7 male and 2 female patients. The mean age of the patients was 13. In addition to an alveolar cleft, 6 patients also had vestibulonasal fistula. It was observed that the volume of the flaps had not changed one year after the operation. The DGI score of all the patients was 24. Existing techniques may be inadequate in the reconstruction of wide and recalcitrant alveolar clefts. MFC flap may be the start of a new era for the treatment of alveolar clefts., Competing Interests: Conflict of interest The authors state that they have no conflicts of interest to disclose., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background and Purpose: Teaching cleft repair in the operating room may not sufficiently prepare craniofacial residents to perform the procedure self-reliantly. This study aimed to assess the influence of surgeons' experience level on the operative time and graft survival ratio after alveolar bone grafts for cleft repair., Subjects and Methods: This was a retrospective review of 100 consecutive alveolar bone graft patients treated for unilateral alveolar cleft by one craniofacial surgeon between 2012 and 2019. An alveolar bone graft from the iliac bone was performed using the lateral sliding flap. Sex, age, cleft width, cleft defect volume, and operative time were recorded, and the 1-year postoperative graft survival ratio was calculated. Multiple regression analysis was performed to identify factors that affect the operative time and survival ratio., Results: Factors affecting the operative time were the experience level of the surgeon and the presence of a cleft palate. Factors affecting the graft survival ratio were the cleft defect volume and experience level of the surgeon. In cleft lip and alveolus, the survival ratio was constant, and the operative time stabilised after approximately 20 cases. In cleft lip and palate, more experience was required to master the technique, and the operative time and survival ratio were stabilised only after approximately 40 cases., Conclusion: Surgeons' experience level influenced the outcomes of alveolar bone grafting. Although surgical training is currently undergoing a paradigm shift from on-the-job training to simulation-based training, clinical experience is critical to be self-sufficient., Competing Interests: Conflict of interest statement None., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: To systematically evaluate the effect of bone morphogenetic protein-2 (BMP-2) and iliac cancellous bone graft (ICBG) on alveolar cleft bone grafting (ACBG) in cleft lip and palate., Method: Online databases were searched for case-control studies related to the application of BMP-2 and ICBG in ACBG., Result: Meta-analysis showed no significant statistical difference in the filling rate (OR = 4.1, 95% CI (0.06, 2.63)), the volume of bone graft area (OR=-0.42, 95% CI (-1.44, 0.60)), the height of bone graft area (OR = -21.38, 95% CI (-23.00, -19.76)), the density of bone graft area (OR = 0.43, 95% CI (-0.79, 1.64)), the failure rate of bone graft (OR = 0.02, 95% CI (-0.03, 0.06)), infection after operation, and the rate (OR = 0.20, 95% CI (0.05, 0.73)) and the incidence of postoperative oronasal fistula (OR = 4.1, 95% CI (0.06, 2.63)) between BMP-2 and ICBG in ACBG. However, there were obvious statistical differences in operative time (OR = -3.64, 95% CI (-7.35, 0.06)) and the length of hospital stay (OR = -1.97, 95% CI (-2.41, -1.53))., Conclusion: The meta-analysis shows that there is no significant difference between BMP-2 and ICBG in filling rate, volume, density, failure rate, and the occurrence of oronasal fistula after ACBG. There were significant differences between BMP-2 and ICBG in the operation time and hospitalization time of ACBG. Compared with ICBG bone graft, BMP-2 has more advantages in ACBG such as remaining area height, postoperative infection rate, operative time, and length of hospital stay., Competing Interests: Declaration of Competing Interest None of the listed authors have conflicts of interest or any disclosures., (Copyright © 2020. Published by Elsevier Ltd.)

Introduction: Bone grafting of alveolar clefts is routinely performed with cancellous bone harvested from the iliac crest. Graft site morbidity is frequently seen, with early postoperative pain being one of the most common complaints. Liposomal bupivacaine (LB) has been demonstrated to provide improvement in postoperative pain for patients undergoing bunionectomy or hemorrhoidectomy, which may translate to patients requiring iliac crest bone graft harvest., Methods: Thirty-eight patients undergoing iliac crest bone harvest were included in the study. Twenty-one patients underwent open iliac crest bone graft harvest with administration of 0.25% bupivacaine at the hip donor site, while 17 patients received local infiltration of 1.3% liposomal bupivacaine. Patient-reported pain scores, total narcotic use, length of stay, and postoperative steps were monitored., Results: There were no significant differences in age, weight, distribution of clefts, or choice of donor hip between the two groups. There were no significant differences in length of hospitalization stay. However, differences were noted in average postoperative pain scores at five of six time points in the first 24 h, total oral morphine equivalents administered (4.7 ± 5.3 vs. 14.3 ± 12.0), and steps at postoperative days one to three (p < 0.001, for all three days) for patients receiving 1.3% LB versus 0.25% bupivacaine, respectively., Conclusion: Reduced pain scores and increased postoperative activity highlight the potential of LB to improve postoperative pain management in children undergoing iliac crest bone harvest for alveolar bone grafting., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: We introduce a method to extract the maximum amount of cancellous bone from the calvarium and analyze the outcomes using plain radiography and computed tomography., Methods: We retrospectively analyzed the medical records of patients who underwent secondary alveolar bone grafts using a maximal harvesting technique for calvarial cancellous bone. Bone survival was determined based on Enemark's grading system using plain radiographs. Alveolar thickness and height were analyzed by computed tomography and compared with radiographic measurements., Results: Our study enrolled 27 patients, 22 unilateral and 5 bilateral, for a total of 32 alveolar clefts. The mean age at surgery was 9.04 ± 0.41 years (range: 6-12 years). Donor sites were successfully recovered without complications, such as hematomas, seromas, infections, or tears in the dura mater. The mean follow-up duration for obtaining plain radiographs was 6.90 ± 0.61 years (range: 2.0-18.50 years). The mean follow-up duration for computed tomography was 6.51 ± 0.99 years (range: 2.0-14.83 years). A canine tooth erupted in 30 cases. Success (Enemark's grades I or II) was achieved in 26 cases. Alveolar height was strongly correlated with the Enemark scale results (γ = 0.878, p < 0.001), but alveolar thickness was not correlated (γ = 0.4575, p = 0.08)., Conclusion: Our cancellous bone harvesting technique resulted in successful graft survival without serious complications, including dural or brain injuries. Although the ilium is widely accepted as the optimal donor site for secondary alveolar bone grafting, the calvarium could be an alternative donor site that results in equivalent outcomes., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background/aim: The purpose of this study is to analyze the risk factors for bone resorption following secondary bone grafting in the alveolar cleft, using three-dimensional (3D) computed tomography (CT) based on surgical simulation software (SimPlant OMS, Materialise Dental, Leuven, Belgium)., Methods: We reviewed the secondary alveolar bone grafts performed by a single surgeon between January 2005 and January 2014. A total of 40 patients with unilateral alveolar cleft were included in this study. The grafted alveolar bone was measured using surgical simulation software. In order to validate the measurement, each data set was measured by three different analysts and the inter- and intraobserver variabilities were calculated. A total of eight risk factors for grafted bone survival, including patient age, sex, body mass index (BMI), palatal fistula, amount of grafted bone, dental appliance, canine or incisor eruption, and preoperative upper respiratory tract infection, were evaluated using the linear mixed model and Mann-Whitney test., Results: The average alveolar defect size was 4.98 cc and the average graft survival was 67.5%. The inter- and intraobserver variabilities of simulation software were 0.758 and 0.915, respectively. Among the risk factors, only dental appliance (p = 0.02) and canine eruption (p = 0.041) were significantly correlated with graft survival. Other risk factors, including the amount of grafted bone, did not show a significant relationship with graft survival., Conclusion: Measurement of an alveolar bone defect using a simulation program based on 3D CT is reliable and reproducible. Secondary bone grafting survival was significantly correlated with canine eruption and dental appliance in the alveolar cleft., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)