Search

To assess the effect of secondary alveolar bone grafting (SABG) on maxillary growth in patients with unilateral cleft lip or palate (UCL/P)., Systematic review and Meta-analysis., Pubmed, Cochrane Library, Embase, Scopus, Web of Science and manual search was performed to assess the maxillary growth following SABG in UCL/P patients., Non-syndromic patients with UCL/P., Comparison of maxillary growth between patients with UCL/P who underwent SABG and UCL/P patients who had not undergone SABG or non-cleft control., 39 of the identified 233 articles were assessed for inclusion and exclusion criteria after duplicate removal and title and abstract reading. 7 articles (1 prospective, and 6 retrospective studies) were included in the qualitative analysis and 2 articles were subjected to quantitative analysis. Four studies had a low risk of bias and three studies had a moderate risk of bias. Meta-analysis revealed a significant reduction of SNA and no significant difference in ANB in the SABG group compared to the non-cleft control group(I 2  = 0%). There was no significant difference in ANB between SABG and non-cleft control; however, results showed high heterogeneity(I 2  = 83%). Meta-analysis of SNA and ANB showed no significant difference between SABG and the cleft control group; however, there was high heterogeneity., The studies showed a low to moderate risk of bias. SABG causes inhibition of maxillary growth in patients with cleft lip or palate when compared to patients with non-cleft control. Due to high heterogeneity, comparison to cleft control showed insufficient evidence., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To analyse the maxillary arch dimensions of children aged 9 and 12 with unilateral cleft lip and palate (UCLP) who received orthodontic treatment and secondary alveolar bone grafting., Design: This retrospective cohort study was performed on 30 patients with UCLP., Setting: All patients were treated at the Cleft Lip and Palate Centre, which is part of the University Medical Centre Amsterdam and Academic Centre for Dentistry Amsterdam, the Netherlands., Patients/participants: Children with non-syndromic UCLP who received pre- and postsurgical orthodontics combined with secondary alveolar bone grafting between the ages of 9 and 12 years were included., Main Outcome Measures: Maxillary arch dimensions were assessed on 60 digitised dental casts with measurements of the intermolar widths, interpremolar widths, arch perimeters, arch lengths, arch widths, and palatal depths., Results: The results of a paired-samples t -test revealed a statistically significant increase ( P  < .05) in intermolar width 1, intermolar width 3, interpremolar width 1, arch perimeter, and arch width between the ages of 9 (T0) and 12 (T1). Intermolar width 2 and the palatal depth decreased statistically significantly between T0 and T1., Conclusions: Analysis of maxillary arch dimensions of children with UCLP indicates significant changes between 9 and 12 years of age. This suggests that orthodontic treatment and secondary alveolar bone grafting can be effective in improving maxillary arch dimensions. However, there is a need for collaborative research and data collection in order to provide sensible and evidence-based care to patients with cleft lip and palate., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To assess the factors influencing the type and timing of Alveolar Bone Grafting (ABG) among cleft centers throughout India. To examine the decision-making criteria for orthodontic treatment and the timing of ABG., Design: Cross sectional survey., Method: This survey was based on a convenience-based sample selected from cleft teams across India. The survey was formulated using the SurveyMonkey platform and emailed to 40 cleft teams. The survey included questions on demographics, timing, surgical protocol, orthodontic protocol, radiograph prescription rate, assessment methods for the success of ABG and three scenarios for evaluating the timing of the bone graft. The Chi-squared test was performed to evaluate the difference in opinion between specialists. The inter-examiner reliability was assessed using Kappa statistics., Results: Thirty-five units completed the questionnaire. Most units operate with 1-2 surgeons, with 42.9% of them treating cleft patients for under 5 years. Only 11.4% of centres routinely advised oblique occlusal radiographs for post-surgery evaluation, and 31.4% prescribed CBCT. However, 40% of cleft teams did not perform audits to evaluate the success of ABG, and less than 50% advised radiographs six months post-surgery. Around 26% of centres do not routinely provide orthodontic treatment pre-ABG. The inter-examiner reliability for case scenarios showed poor agreement between the clinicians., Conclusion: The survey showed a serious lack of consensus in the ABG treatment among cleft teams in India and emphasises the need for standardised protocols for the treatment of children with cleft palate. There is an urgent need to develop core outcome set in cleft., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Evaluate periodontal bone support of maxillary central incisors (MCI) in patients with bilateral complete cleft lip and palate (BCCLP). Determine if syndromic diagnosis, age at time of alveolar bone graft (ABG), presence of maxillary lateral incisor (MLI), history of dentofacial orthopedics, maxillary expansion, and pre-maxillary osteotomy are associated with the periodontal bone support of MCI., Retrospective radiographic study., Tertiary care children's hospital., One hundred seventy-nine patients with BCCLP (22 syndromic) who had post-operative ABG cone beam computed tomography (CBCT) scans taken between 2002-2018., Crown to root ( C/R) ratio of MCI measured on CBCT scans., The C/R ratio in 65% of MCI indicated periodontally compromised teeth. Presence of a MLI improved bone support on adjacent MCI when compared to those missing a MLI (51.4% vs 28.4%, P  = .010). There was no significant difference in C/R ratios for syndromic diagnosis, age at ABG, history of dentofacial orthopedics, maxillary expansion, and pre-maxillary osteotomy., The majority of MCI in patients with BCCLP are periodontally compromised but bone support is improved when cleft adjacent lateral incisors are present., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To evaluate the outcomes of Secondary Alveolar Bone Grafting (SABG) in patients treated either in daycare or with multiple day hospitalization (MDH) in relation to costs and complication rates., Design: Retrospective comparative cohort study., Setting: The data was collected from two settings: Postoperative daycare or MDH after oral cleft surgery in an Academic Medical Center in The Netherlands., Patients: Data of 137 patients with unilateral Cleft lip, alveolus, and palate (CLAP) treated between 2006-2018 were evaluated. Registered clinical variables: age, gender, cleft subtype, bone donor site, type of hospitalization, length of stay, additional surgery, complications, surgeons, and costs., Interventions: Closure of the alveolar cleft with/without closure of the anterior palate., Main Outcome Measures: Univariate analyses., Results: Of the 137 patients, 46.7% were treated in MDH, and 53.3% in daycare. Total costs for daycare were significantly lower ( P  < .001). All patients treated in daycare received mandibular symphysis bone, whereas in MDH, 46.9% received iliac crest bone instead. Bone donor site was associated with postoperative care type. Complication rates were slightly but not significantly higher in daycare (26%) vs. MDH (14.1%) ( P  = .09). Most were Grade I (minor) according to Clavien Dindo classification., Conclusions: Daycare after alveolar cleft surgery is about as safe as MDH, but significantly cheaper., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: This study investigates the effectiveness of demineralized bone matrix (DBX) to close alveolar clefts in patients previously treated with bone morphogenic protein-2 (BMP-2) who remained with bone nonunion., Design: This is an IRB-approved retrospective, single-center study., Setting: This study was conducted at a tertiary academic center., Patients/participants: We searched for all surgical encounters with the Current Procedural Terminology (CPT) code 42210 from the years 2013-2019. Included patients were diagnosed with cleft alveolus, previous BMP-2 exposure and required revision bone grafting during mixed dentition for persistent alveolar defects., Interventions: 17 patients underwent revision alveolar bone grafting (ABG) with either DBX (n = 10) or autograft (n = 7) to repair persistent bony cleft., Main Outcome Measure(s): The primary study outcome measured was alveolar bone graft revision failure described as continued alveolar nonunion., Results: The median age at revision ABG was 13.1 ± 3.3 years, with a mean follow-up time of 4.9 years (1.1-9.2 years). Patients were 53% male, 47% had a unilateral cleft lip and alveolus. 58.8% of patients were treated with DBX in the cleft, 41.2% treated with autograft from iliac crest. Overall, 11.8% (n = 2) of all revisions failed, requiring a second revision. The average time to reoperation was 2.06 years, and both were re-grafted with autograft. There was no statistically significant difference between the type of bone graft source used and the failure rate obtained ( P  = .1544)., Conclusions: DBX and autologous iliac crest bone grafts achieve similar alveolar union rates during revision ABG in patients treated with previous BMP-2 to the alveolar cleft., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The purpose is to evaluate outcomes of alveolar bone grafting based on the pre-grafting orthodontic preparation methods., Design: Retrospective analysis of individuals with unilateral cleft lip and palate., Subjects and Settings: 28 individuals with non-syndromic UCLP from two craniofacial centers, 14 individuals each from XXXX and XXXX., Interventions: The alignment group underwent maxillary expansion with incisors alignment while the non-alignment group underwent only maxillary expansion for presurgical orthodontic preparation., Methods: Initial and post-surgical CBCT scans were compared to observe changes in angulation of the incisor adjacent to the cleft site, alveolar bony root coverage, and bone graft outcomes., Results: In the alignment group, the buccolingual rotation decreased by 32.35 degrees ( p  = .0002), the anteroposterior inclination increased by 14.01 degrees ( p  = .0004), and the mesiodistal angulation decreased by 17.88 degrees ( p  = .0001). Alveolar bony coverage did not change after bone graft in both groups, and no difference was observed between the groups. Chelsea scale showed satisfactory bone graft outcome (category A, C) in 12 cases (85.71%) in the alignment group and 11 cases (78.51%) in the non-alignment group. The volumetric measurement showed the alignment group had better bone fill of 69.85% versus 51.45% in the non-alignment group ( p  = .0495)., Conclusions: Alveolar bony coverage on the tooth adjacent to cleft sites did not change with alveolar bone grafting surgery in either of the alignment and non-alignment group. Presurgical orthodontic alignment does not induce root exposure nor poorer bone grafting outcome., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Alveolar bone grafting aims to restore bony continuity of the alveolus and provide optimal periodontal support for teeth adjacent to the cleft. We created a survey of cleft surgeons to assess the current standard of care regarding this procedure., Methods: A multiple choice survey was implemented using Qualtrics software and emailed to a list of 708 surgeons from the ACPA membership directory. Correlation between various provider factors and treatment practices was assessed with Fisher's exact test and likelihood ratio tests., Results: The response rate was 17.5%. Eighty-seven percent of providers preferred to perform grafts prior to secondary canine eruption while 10% favored before central incisor eruption. Eighty-one percent favored palatal expansion prior to bone grafting. Wide variability existed regarding the time to initiate postoperative orthodontics; 43% waited 4 to 6 months. Sixty-four percent of surgeons now utilize cone beam CT to assess graft take. The majority of respondents utilized cancellous bone autograft (92%) from the anterior iliac crest (97%) as graft material. Seventy percent used three or more modalities for post-operative pain control management. Early career surgeons (0-5 years) appeared more likely to use non-autologous materials ( p  < .01) for grafting., Conclusion: Alveolar bone grafting prior to secondary canine eruption remains the most common strategy but other protocols are employed. Surgeons utilize multiple modalities for radiographic evaluation and most often use autologous cancellous bone as the primary grafting material. There is no true consensus on the perioperative timing and sequencing of orthodontic manipulation while principles of multimodal perioperative pain control appear widely accepted., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The purpose of this study is to determine areas of agreement and disagreement among American Cleft Palate-Craniofacial Association (ACPA)members in the clinical practice of alveolar bone grafting (ABG), to guide further research to optimize ABG practices., A cross-sectional survey was conducted., The respondents were in an academic, combination, or private practice., The respondents were either plastic or oral and maxillofacial surgeons (OMFS) from various countries., A de-identified 24-question online survey was distributed to ACPA surgeon members utilizing the Research Electronic Data Capture (REDCap) tool., Data collected included surgeon specialty, use of various alveolar bone graft surgical techniques, as well as protocols., There was more variability than consensus between specialties with regards to the preoperative workup, timing of surgery, materials used for bone graft, surgical techniques, perioperative management, and postoperative evaluation. There was consensus on grafting during mixed dentition, not staging soft and hard tissue closure, and using iliac crest for primary and secondary grafting. Disagreements involved factors used to time the procedure and type of imaging used to assess viability. Technical differences involved incision type, part of bone grafted, use of minimally invasive technique, and material used for revisions., Aside from areas of consensus among surgeons on ABG, several areas, including use of bone substitutes in revision grafting, incision and type of iliac crest graft used during initial grafting, and postoperative protocols, had no consensus. These areas should be targets of further research to determine if there truly is an optimal method to perform ABG., The study was approved by the University of Illinois at Chicago Institutional Review Board. A de-identified 24-question online survey was distributed to surgeon members of the ACPA utilizing the REDCap tool on August 7, 2020. The survey questions consisted of multiple choice and multiple selection questions including an option to select "other" and specify the information in a blank space. Data collected included surgeon specialty, use of various alveolar bone graft surgical techniques, as well as pre and postoperative protocols. The full survey is included in online Supplemental material. Data analysis was performed in SPSS Statistics 27 (IBM Corp.). Descriptive statistics were performed, and chi-square was used to test for significant differences in survey responses between groups., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Standard bone grafting between ages 6 and 12 has become the preferred treatment of choice for alveolar clefts. Given the importance of surgical timing in complete cleft palate repairs, it is important to identify any populations at-risk for delayed alveolar bone grafting. The purpose of this study is to identify whether a racial disparity is present nationally in the timing of alveolar bone grafting., Retrospective analysis Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)., Inclusion criteria involved patients who underwent alveolar bone grafting identified by current procedure terminology (CPT) code 42210 between years 2012 and 2019. Patients were stratified by age at time of operation based on the following parameters: early bone grafting (before 6 years of age), standard bone grafting (between 6 and 12 years of age), and late bone grafting (after 12 years of age)., Racial and ethnic differences in the age of patients at the time of alveolar bone grafting., Overall, 20.28% of the cohort received alveolar bone graft after 12 years of age. African American (29.33%) and Hispanic (24.42%) patients received late alveolar bone grafting more frequently than other racial and ethnic groups ( P  < .001)., Racial and ethnic disparities are present in the frequency at which patients receive late alveolar bone grafting for complete cleft palates. Given the suboptimal surgical results of late compared to standard alveolar bone grafting it is important to further investigate the driving factors of these disparities.

Objective: To report current diagnostic protocols, practices, and barriers related to imaging of alveolar clefting among American Cleft Palate-Craniofacial Association (ACPA)-approved cleft/craniofacial teams., Methods: An electronic survey was sent to 162 ACPA-approved teams in the United States. Key items were team location, venue of orthodontic treatment, imaging modality(s) and access, barriers to imaging, billing, imaging protocols including team members involved in decisions pre- and post-alveolar bone grafting (ABG), and craniofacial fellowship status of team orthodontist(s)., Results: A total of 66 responses were received (40.7%). Responding teams were university-based (47%), hospital-based (42.4%), and independent clinics (10.6%). Orthodontic treatment for most patients was in private practice (53%). On-site 2-dimensional (2D) and 3-dimensional (3D) dental imaging capabilities were reported by 42% of teams; 29% have no on-site imaging. One or more barrier(s) to acquiring imaging were reported by 67%, with insurance challenges reported by 47%. Most teams bill medical payors for cleft-related dental imaging (58%). Pre- and post-ABG imaging was most frequently 3D (35% and 36%, respectively). Surgeons and orthodontists commonly evaluate ABG timing and outcome together (53%-65%). Periapical radiographs were included significantly more often in cleft imaging protocols by orthodontists with versus without fellowship training ( P  = .011, P  = .04)., Conclusions: Barriers to acquiring imaging are frequent. 3D is the most common imaging pre- and post-ABG. Our study endorses multi-level advocacy for improved medical insurance coverage of diagnostic cleft-related dental imaging to decrease barriers to providing timely care.

Objective: To evaluate the reproducibility and accuracy of a new, easy-to-use volumetric assessment of the alveolar cleft., Design: Twelve cone-beam computed tomography (CBCT) datasets of patients with a unilateral cleft lip, alveolus, and palate were evaluated by two investigators. Residual alveolar cleft calcified volume one year after surgery was analyzed by using standardized landmarks to determine the borders of the cleft defect and semi-automatically segment the alveolar cleft defect., Results: The Dice-coefficient between observers for the segmented preoperative alveolar cleft defect was 0.81. Average percentage of residual alveolar cleft calcified material was 66.7% one year postoperatively., Conclusions: This study demonstrates a reliable and practical semi-automatic three-dimensional volumetric assessment method for unilateral clefts using CBCT.

Background: Imaging findings are central to the diagnosis and treatment planning decisions when managing craniofacial differences. However, limited information is published on protocols for systematic cleft imaging assessment and for effective communication of these findings., Solution: A template is presented to help guide radiologic imaging reports to acquire the relevant clinical information needed to manage patients with alveolar cleft.

Objective: This study aimed to review all research evidence of presurgical cleft size and related factors to success of secondary alveolar bone grafting (SABG)., Design and Setting: The systematic review searched the OVID-Medline®, PubMed®, Embase®, and Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2020. Two reviewers independently selected potential abstracts for full review. Disagreeements were resolved by consensus. The first author extracted data and assessed the risk of bias using Risk of Bias in Non-randomized studies-of Interventions tool., Patients and Interventions: Patients with non-syndromic clefts who received SABG were selected. Presurgical cleft size/volume and treatment results must be available., Main Outcome Measures: Level of the grafted bone, achievement of orthodontic tooth movement into the grafted area, need for re-operation., Results: From 962 abstracts, 23 publications were included. Mean cleft width was 6.80 ± 1.98 mm, cleft area 20-240 mm 2 , and mean volume 0.89 ± 0.33 cm 3 . No definite conclusion was achieved on whether a narrow or wide cleft showed better treatment outcomes, but other potentially related factors were good oral hygiene and eruptive force of the maxillary canines. Lack of a standard definition of cleft size, a small sample size, varying outcome parameters, and moderate-to-high risk of bias contributed to the summary. A meta-analysis could not be performed because of the heterogeneity., Conclusion: Due to insufficient evidence, cleft width/volume could not be specified leading to more successful SABG. Care of patients could be improved in both research by following rigorous methodology, and practice by clear communication.

Primary CL/P repair, revisions, and secondary procedures-cleft rhinoplasty, speech surgery, and alveolar bone grafting (ABG)-performed from 2014-2018 were identified from the Pediatric National Surgical Quality Improvement Program (NSQIP) database. Utilization estimates were derived via univariable and multivariable logistic regression. A Kruskal-Wallis rank-sum test and multivariable linear regression were used to assess differences in timing for each procedure cohort., The primary outcome measures were the odds of a patient being a certain race/ethnicity, and the age at which patients of different race/ethnicity receive surgery., There were 23 780 procedures analyzed. After controlling for sex, diagnosis, and functional status, there were significant differences in utilization estimates across procedure groups. Primarily, utilization was lowest in patient who were Black for cleft rhinoplasty (OR = 0.70, P  = .023), ABG (OR = 0.44, P  < .001) and speech surgery (OR = 0.57, P  = .012), and highest in patients who were Asian patients in all surgery cohorts (OR 2.05-4.43). Timing of surgery also varied by race, although differences were minimal., Conclusions: Estimates of utilization and timing of secondary cleft procedures varied by race, particularly among patients who were Black (poor utilization) or Asian (high utilization). Further studies should identify the causes and implications of underutilized and/or delayed cleft care.

Objective: To determine if secondary alveolar bone grafting (SABG) timing in patients with cleft lip and palate (CLP) influences the future need for additional maxillary advancement procedures, particularly Le Fort I osteotomy with rigid external distraction (RED)., Design: Retrospective cohort study. Groups were separated by SABG timing: early mixed dentition (ages 68 years) or late mixed dentition (ages 9-11 years). The criterion for RED was negative overjet ≥8 mm, and sufficient dental development for RED., Setting: Single tertiary care institution., Patients: Patients with CLP that underwent SABG from 2010 to 2015. Exclusion criteria included syndromic conditions, SABG surgery at age >12 years, current age <12 years, and <2 years follow-up. 104 patients were included., Main Outcome Measures: The number of RED candidates and treated patients., Results: There was no statistical difference in the number of RED candidates ( P   =  .0718) nor treated patients ( P   =  .2716) based on SABG timing; stratification by laterality was also insignificant. Early SABG is associated with higher odds of being a RED candidate (pooled, unilateral, bilateral) and treated patient (pooled and unilateral); however, there were no statistically significant associations between SABG timing and the number of RED candidates and treated patients as determined by logistic regression models., Conclusion: There is no statistically significant association between SABG timing and the odds of being a RED candidate or treated patient. Future prospective studies are recommended to assess the relationship between SABG timing and maxillary growth in patients with CLP.

Objective: Comparison between bovine-derived demineralized bone matrix (DMBM) and iliac crest graft over long term for secondary alveolar bone grafting (SABG) in patients with unilateral cleft lip and palate (UCLP) in terms of radiological and clinical outcomes., Design: Prospective, randomized, parallel groups, double-blind, controlled trial., Setting: Unit of Oral and Maxillofacial Surgery, Oral Health Science Centre, Postgraduate Institute of Medical Education & Research, Chandigarh., Participants: Twenty patients with UCLP., Interventions: Patients were allocated into group I (Iliac crest bone graft) and group II (DMBM) for SABG. Outcomes were assessed at 2 weeks, 6 months, and then after mean follow-up period of 63 months., Outcomes Measures: Volumetric analysis of the grafted bone in the alveolar cleft site was done through cone beam computed tomography using Cavalieri principle and modified assessment tool. Clinical assessment was performed in terms of pain, swelling, duration of hospital stay, cost of surgery, alar base symmetry, and donor site morbidity associated with iliac crest harvesting., Results: Volumetric analysis through Cavalieri principle revealed comparable bone uptake at follow-up of 6 months between group I (70%) and group II (69%). Modified assessment tool showed no significant difference between horizontal and vertical bone scores over short- and long-term follow-up. In group II, there was higher cost of surgery, but no donor site morbidity unlike group I., Conclusions: Demineralized bone matrix proved analogous to iliac crest bone graft as per volumetric analysis over shorter period. However, although statistically insignificant, net bone volume achieved was lower than the iliac crest graft at longer follow-up.

Introduction: Since the early stages of alveolar bone grafting development, multiple types of materials have been used. Iliac cancellous bone graft (ICBG) remains the gold standard., Design/methods: A review of literature is conducted in order to describe the different bone filling possibilities, autologous or not, and to assess their effectiveness compared to ICBG. This review focused on studies reporting volumetric assessment of the alveolar cleft graft result (by computed tomography scan or cone beam computed tomography)., Results: Grafting materials fall into 3 types: autologous bone grafts, ICBG supplementary material, and bone substitutes. Among autologous materials, no study showed the superiority of any other bone origin over iliac cancellous bone. Yet ICBG gives inconsistent results and presents donor site morbidity. Concerning supplementary material, only 3 studies could show a benefit of adding platelet-rich fibrin (1 study) or platelet-rich plasma (2 studies) to ICBG, which remains controversial in most studies. There is a lack of 3-dimensional (3D) assessment in most articles concerning the use of scaffolds. Only one study showed graft improvement when adding acellular dermal matrix to ICBG. Looking at bone substitutes highlights failures among bioceramics alone, side-effects with bone morphogenetic protein-2 composite materials, and difficulties in cell therapy setup. Studies assessing cell therapy-based substitutes show comparable efficacy with ICBG but remain too few., Conclusion: This review highlights the lack of 3D assessments in the alveolar bone graft materials field. Nothing dethroned ICBG from its position as the gold standard treatment at this time.

Objective: We aim to establish consistent time points for evaluating palatal fistula incidence to standardize reporting practices and clarify prospective literature., Design: An institutional retrospective chart review was conducted on 76 patients with unilateral or bilateral complete cleft lip and palate who underwent secondary alveolar bone grafting between 2006 and 2015., Main Outcome Measures: Early fistula incidence rates were reported prior to maxillary expansion, and late fistula rates were reported at the time of alveolar bone grafting. Fistula recurrence rates after primary repair were also measured., Results: We found an early fistula incidence rate of 20% (n = 15) and a late fistula rate of 55% (n = 42) at the time of secondary ABG. Fistulae recurred after initial repair in 43% of cases. Fistulae were classified using the Pittsburgh Classification System as type III (33%), type IV (60%), or type V (7%). The presence of a bilateral cleft ( P = 0.01) and history of early fistula repair ( P < 0.01) were associated with late fistula incidence in a univariate analysis. In a logistic regression model, only early fistula repair was associated with late fistula incidence (OR = 17.17) and overall likelihood of recurrence (OR = 70.89)., Conclusions: Early fistulae should be reported prior to orthodontic expansion of the maxillary arch. Late fistulae should be reported at the time of ABG, following palatal expansion. Patients who develop an early fistula after palatoplasty are likely to experience recurrent fistula formation.

Objective: Dexmedetomidine is a parenteral agent that combines the benefits of cooperative sedation, anxiolysis, and analgesia without the risks of respiratory depression. Off-label use has been reported in children. We have introduced dexmedetomidine for use in patients having undergone alveolar bone graft (ABG). The objective is to demonstrate the value and safety of postoperative dexmedetomidine infusion in a non-ICU setting following ABG., Design: A retrospective review was performed on patients who underwent ABG by the senior author. Patients were divided into 2 groups: those who received postoperative dexmedetomidine and those who received patient-controlled anesthesia., Main Outcome Measure(s): The primary study outcome measures included patient demographics, adverse events, length of stay, pain scores, and doses of narcotics during admission were collected., Results: Inclusion criteria were met by 54 patients; 39 received dexmedetomidine whereas 15 did not. There were no significant differences between groups in age, gender, and length of stay. The patients who received dexmedetomidine used oral narcotics less often ( P = .01). In addition, more patients reported no pain after surgery ( P = .05) and at the time of discharge if they received dexmedetomidine ( P < .01). There were no reported adverse effects., Conclusions: Dexmedetomidine provided superior pain control after surgery and at the time of discharge, as well as a significant decrease in the use of oral narcotics. In our institution, it has since replaced the PCA as a postoperative pain control modality. Absent the risk for respiratory depression, dexmedetomidine has demonstrated a safe option for postoperative pain control in our focused group of pediatric patients.

Objective: To compare the bone morphology after secondary alveolar bone graft surgery (SABG) performed before and after permanent canine eruption., Design: Cross-sectional study., Setting: Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, SP, Brazil., Patients: 25 cone-beam computed tomography (CBCT) scans of complete unilateral cleft lip and palate (CLP) individuals who underwent SABG before or after eruption of the permanent canine taken 2 and 6 months (T1 and T2) after SAGB, resulting in 50 CBCT scans. Two groups were assessed, Ideal Group (IG; n = 10) and Late Group (LG; n = 15), according to the time of the SABG., Interventions: SABG buccal-palatal thicknesses were measured in 3 different root levels: cement-enamel junction (cervical slice), middle point of the root (intermediate slice), and apex of the central incisor (apical slice). Thickness measurements were assessed in the mesial, distal, and intermediate aspects of the alveolar bone graft. Clinical long-term follow-up was also done., Results: The IG showed significantly greater bone thickness, especially in the intermediate and apical slices, when compared to LG, in T1 and T2. Bone thickness was maintained over time. Clinically, all the IG individuals completed orthodontics, and no major complications were observed. In contrast, 27% of the LG individuals had failures, and rehabilitation was achieved through prosthesis., Conclusion: Ideal SABG presents with better results compared with late ABG. When it is not possible to perform SABG at the ideal time, acceptable outcomes still can be expected for late bone grafting.

Objectives: To investigate examiner reliability of scoring intraoral radiographs of bone infill following secondary bone grafting using a categorical scale (modified Kindelan Index) and a 10-cm visual analog scale (VAS). To investigate the level of clinical experience on the reliability of these assessments., Design: Retrospective study involving 10 clinicians of varying clinical experience who were blind to the patient's identity., Setting: All grafting was carried out within the New Zealand public hospital service., Patients: Fifty-eight grafts (48 UCLP and 5 BCLP) were assessed with 14 duplicated radiographs randomly added to the sample, making a total of 72 radiographs for assessment., Main Outcome Measures: Weighted kappa was used for intra- and interrater examiner reliability for the categorical scale and correlations for the VAS., Results: Relatively poor intrarater examiner agreement for categorical scoring (median 0.46) was found. Clinicians with greater experience generally recording higher intrarater weighted kappa. The intrarater correlations for the continuous scale (median 0.89) suggest better consistency regardless of the level of experience. The interrater relationships were generally low, with an average of weighted kappa of 0.25 while the overall average VAS correlation was 0.49. For the majority of scorers, there was a relationship between the VAS and the Kindelan Index, with lower VAS scores related to worse Kindelan scores., Conclusions: The use of a VAS produced better intra- and interexaminer reliability than the categorical Kindelan Index and was more consistent despite the level of clinical experience. Further evaluation of the validity of the VAS for the assessment of bone infill is warranted.

Objective: The objective of this study was to test a new method, a Standardized Way to Assess Grafts (SWAG), to rate alveolar bone graft (ABG) outcomes for patients with cleft lip and palate., Design: This was a retrospective comparison using the SWAG scale., Setting: This study took place in four cleft palate centers with different treatment protocols., Methods: A total of 160 maxillary occlusal radiographs taken 3 to 18 months post-ABG for sequentially treated patients with cleft lip and palate were assessed using the SWAG scale. Radiographs were scanned, standardized, blinded, and rated by 6 calibrated orthodontists to assess vertical thirds, bony root coverage, and complete bony fill. All radiographs were rated twice, 24 hours apart, by the same raters., Main Outcomes: Intra- and interrater reliabilities were assessed., Results: Intrarater reliability was good to very good (.760; .652-.834), and interrater reliability was moderate to good (.606; .569-.681), comparable to previously published methods., Conclusions: Rater reliabilities were shown to be comparable to or better than existing methods. The SWAG method was validated for ABG assessments in the mixed and permanent dentitions based on reliabilities in an intercenter outcome comparison.

Objective: The aim of this study was to investigate clinical aspects and predisposing factors for alveolar bone graft complications in persons born with oral clefts., Design: A total of 105 patients, aged 7 to 57 years old, who received alveolar bone graft at the Cranio-maxillofacial Surgery Center in the National Institute of Traumatology and Orthopedics (INTO), Rio de Janeiro (RJ) from 2009 to 2014 were selected. Data were collected concerning the type of oral cleft, family history of cleft, medical and dental exam, donor area, type of graft material, repaired surgical treatment done, and postoperative follow-up examinations., Results: Postoperative complications developed in 31 patients (32.9%). The mean age at grafting was 16.79 years for the group without complications (n = 63) and 20.13 years for the group with postoperative complications (n = 31). There was a positive association between age and type of graft and cases with alveolar bone graft complications. Patients aged 12 years or more had a four times more chance of developing alveolar bone graft complications. Particulate bone graft from iliac crest demonstrated better results compared with block graft or mixed graft., Conclusion: Patients with cleft lip and palate who were 12 years or older had a greater chance of developing complications after grafting the alveolar bone. Furthermore, particulate alveolar graft from iliac crest had significantly better outcomes.

Objective: To compare effects of secondary cleft procedures on alar base position and nostril morphology., Design: Retrospective review., Setting: Multidisciplinary cleft clinic at tertiary center., Patients, Participants: Seventy consecutive patients with unilateral clefts were grouped according to secondary procedure., Interventions: Alveolar bone graft versus total lip takedown with anatomic muscle repair versus single-stage total lip with cleft septorhinoplasty (nose-lip) versus rhinoplasty alone., Main Outcome Measures: Anthropometric measurements were recorded from pre- and postoperative photographs. Ratios of cleft to noncleft side were compared within and across groups pre- and postoperatively using parametric and nonparametric tests., Results: Within the bone graft group, no differences were seen postoperatively in alar base position in long-term follow-up. The total lip group demonstrated greater symmetry at the alar base (P < .001), increased vertical lip dimension (P < .001), and decreased nostril height (P = .004) postoperatively. Within the nose-lip group, increased vertical dimension and alar base support (P < .001) were also seen postoperatively. Across groups, the single-stage nose-lip group demonstrated greatest alar base symmetry on worm's-eye view (P < .04)., Conclusions: Alar base asymmetry in patients with unilateral clefts may be related to soft tissue deficiency and was not affected by alveolar bone grafting. Total lip takedown with anatomic muscle reapproximation was associated with increased alar base symmetry and vertical lip dimension on cleft to noncleft side. Greatest symmetry at the alar base was seen following single-stage nose-lip reconstruction, which may be an effective technique for correcting the secondary cleft lip nasal deformity.

Objective: To report the surgical outcomes of secondary alveolar bone grafting with premaxillary osteotomy in a single surgeon cohort of complete bilateral cleft lip and palate patients., Design: Retrospective review of 44 consecutive patients using hospital notes and radiographs., Setting: Single specialist cleft lip and palate center, UK., Patients: Consecutive patients with complete bilateral cleft lip and palate who were being treated with secondary alveolar bone grafting incorporating premaxillary osteotomy., Outcome Measures: Assessment of success of bone graft by Kindelan score; canine eruption; closure of fistulae and assessment of morbidity., Results: Between January 6, 2000, and August 8, 2013, 44 patients with complete BCLP underwent secondary ABG with a premaxillary osteotomy as a one-stage procedure. The mean follow-up was 7.3 years (range 1.4 to 14.6). Eighty-five percent of ABGs were successful (a Kindelan score of 1 or 2), and canine eruption was 89%. Failure of the ABG occurred in 7%. Fistulae recurrence rate was 11%, all of which were asymptomatic. No premaxillae were devitalized., Conclusion: Incorporating a premaxillary osteotomy into the secondary ABG surgical protocol can be a safe technique that gives excellent surgical exposure for fistula repair.

Objective: Review of patients who underwent secondary alveolar bone grafting for total inpatient stay, postoperative complications, and postoperative analgesic requirements., Design: Retrospective analysis of medical records., Setting: Tertiary care center as part of a regional cleft lip and palate network., Patients: All patients who underwent secondary alveolar bone grafting from the iliac crest., Interventions: Local anesthetic was infiltrated overlying the anterior iliac crest. An incision was made to conform to the future skin crease and avoid muscle dissection. The cartilaginous cap was incised and raised, and cancellous bone was then harvested. The cavity was packed with hemostatic cellulose and closed in layers. All patients received postoperative antibiotics. All patients were prescribed regular paracetamol (acetaminophen) and ibuprofen if there were no contraindications. Oral morphine was available when requested., Main Outcome Measures: Length of stay, postoperative analgesic requirements, and postoperative donor site and oral complications., Results: From 100 consecutive patients, 92 (92%) of the patients were discharged the day after surgery; one (1%) patient required four nights of monitoring for postoperative pyrexia of unknown origin. All patients received regular paracetamol, and the majority (86%) did not require oral morphine. Complications included seroma (4%), superficial donor site abscess (1%), postoperative pyrexia of unknown origin (2%), gingival bleeding (2%), and oral infection (2%)., Conclusion: The findings suggest that donor site pain may be well controlled with simple, regular analgesia. Children tolerated this procedure well and were safely discharged the day after surgery. Alveolar bone grafting from the iliac crest was found to have low complication rates.

Objective: This study sought to determine the timing of alveolar bone grafting (ABG) surgery among children with cleft lip with or without cleft palate (CL±P) with regard to race and insurance status., Design: A retrospective chart review of consecutive patients receiving ABG surgery was conducted. A multivariate regression model was constructed using predetermined clinical and demographic variables., Setting: A large, urban cleft referral center., Patients, Participants: Nonsyndromic patients with CL±P were eligible for study inclusion., Interventions: ABG surgery using autogenous bone harvested from the anterior iliac crest., Main Outcome Measure: The primary outcome of interest was age at ABG surgery., Results: A total of 233 patients underwent ABG surgery at 8.1 ± 2.3 years of age. African American and Hispanic patients received delayed ABG surgery compared with Caucasian patients by approximately 1 year (P < .05). There was no difference in ABG surgery timing by insurance status (P > .05)., Conclusions: The timing of ABG surgery varied by race but not by insurance status. Greater resources may be needed to ensure timely delivery of cleft care to African American and Hispanic children.

Objective: The aims of this retrospective study were to evaluate the volumetric outcome of mandibular symphyseal bone graft in patients with unilateral cleft lip and palate by estimating the bone fill 1-year postoperatively on cone beam computed tomography. The outcome was assessed in relation to the (1) root development stage of the cleft side canine, (2) presence/absence of a cleft side lateral incisor, and (3) volume size of the preoperative cleft defect., Methods: The alveolar bone defect volume of 32 consecutive unilateral cleft lip and palate patients aged 8 years 1 month to 11 years 11 months was evaluated using a recently defined and standardized protocol. The outcome was calculated as the percentage of bone fill using the formula (VOLpre - VOLpost) / VOLpre) × 100., Results: The preoperative mean alveolar cleft volume was 934 mm(3), and the average percentage bone fill was 87%. There was no significant difference between bone fill and root developmental stage of the cleft-side canine (P = .882) nor presence/absence of the cleft side lateral incisor (P = .803). The size of the cleft defect did not correlate with the bone fill (r = .03, P = .84)., Conclusions: Secondary alveolar bone grafting with mandibular symphyseal bone graft in patients with unilateral cleft lip and palate is an attractive procedure assessed from the volumetric outcome using cone beam computed tomography. The 1-year average bone fill of 87% was not significantly influenced by root development stage of the cleft-side canine, presence or the absence of a cleft side lateral incisor, or size of the alveolar defect.

Objective : To establish for the first time the prevalence of fistula symptoms and the effectiveness of secondary alveolar bone grafting to treat these symptoms in a single surgeon cohort in Bristol, United Kingdom. Design : Direct questioning of 233 consecutive patients with cleft before and after secondary alveolar bone grafting as to the presence of fistula symptoms. Setting : Southwest and South Wales Cleft Centre, Frenchay Hospital, Bristol, United Kingdom. Participants : Consecutive patients with cleft who were being treated for secondary alveolar bone grafting. Outcome Measure : Patients reporting presence of fistula symptoms. Data collection on cleft type (unilateral, bilateral), date of birth, and age at secondary alveolar bone grafting. Results : Of the 167 unilateral patients with cleft lip and palate and 66 patients with bilateral cleft lip and palate, 45% had symptoms of a fistula before alveolar bone grafting and 10% had symptoms of a fistula after surgery. There were no statistically significant differences between the presence of symptoms before or after secondary alveolar bone grafting between cleft types or by age at secondary alveolar bone grafting. Conclusion : This is the first study examining the rates of fistula symptoms before and after secondary alveolar bone grafting in the United Kingdom. This study used the patient-centered outcome of the presence of symptoms as a way of measuring the presence of fistulas in this group. Secondary alveolar bone grafting reduces the incidence of symptomatic fistula in this setting.

The objective of this analytical cross-sectional study was to develop and test a new clinical evaluation method, using two sets of clinical criteria: (1) probing depth for teeth at either side of the grafted region and (2) residual defect at the central faciolingual region of the alveolar bone graft site, for assessing alveolar bone graft outcomes in patients with cleft of the lip and palate. Thirteen patients, 8 to 13 years old, with cleft lip and palate who underwent alveolar bone graft at Srinagarind Hospital and Faculty of Dentistry of Khon Kaen University were recruited into the study to test the agreement between two sets of data: (1) clinical examination scores and an expert's clinical judgment, (2) clinical and radiographic examination scores (Bergland and Chelsea scales). Study results showed that between the two criteria used in the new clinical method, reliability of the first criterion was higher than that of the second, .66 to 1.00 and .59 to .65, respectively. The reliability test for radiographic evaluation showed that the Chelsea scale had higher agreement than the Bergland, .80 to 1.00 and .64 to .86, respectively. Sensitivity, specificity, and likelihood ratio of the three proposed methods could not be concluded statistically due to the small sample size. In conclusion, even though the study sample was small, the method offers useful prospects as a supplement, if not an alternative, to overcome identified deficiencies of the Bergland and Chelsea scales and computed tomography scans, which raise concerns about radiation hazards and costs.

Objective: To assess and develop a monocortical mandibular bone grafting procedure for reconstruction of alveolar cleft., Design: Prospective study., Setting: Hokkaido University Hospital., Patients: Forty-two consecutive Japanese patients who had been treated for a total of 48 clefts according to a strict clinical protocol. Mean age at bone grafting was 6 years 11 months., Interventions: Bone grafting was performed by harvesting lateral cortical bone plates from the symphysis and/or body and then placing them on the labial and palatal openings of the alveolar process defect. No particulate bone grafts were packed into the bony cavity. Mean follow-up after bone grafting was 37 months., Main Outcome Measures: Status of the grafted area and eruption of cleft-adjacent teeth were assessed prospectively using computed tomography and periapical radiography., Results: At 6 months postoperatively, computed tomography showed sufficient bone bridge formation at the cleft site in 85.4% of clefts. Periapical radiography showed ≥75% of the root surfaces of cleft-adjacent teeth were covered with spanning bone in 83.3% of clefts. In 92.6% of clefts in which the cleft-adjacent canine was uncovered with bone during follow-up, the canines erupted spontaneously., Conclusions: Monocortical mandibular bone grafting appears extremely effective for sufficient bone bridge formation and facilitation of cleft-adjacent teeth eruption. The procedure is advantageous in that the quantity of bone required per unit volume of cleft defect is relatively reduced, and larger clefts can thus be treated.

Objective: To evaluate the eruption path of the permanent maxillary canine during a 1-year period after secondary alveolar bone grafting and to (1) compare the canine eruption path on the cleft and noncleft side, (2) examine the number of congenially missing lateral incisors and the rate of canine impaction, and (3) examine the relationship between the eruption status of the canine and timing of alveolar bone grafting relative to age and canine root development using cone beam computed tomography (CBCT)., Methods: Cone beam computed tomography scans for 17 nonsyndromic unilateral cleft lip and palate (UCLP), and four bilateral cleft lip and palate (BCLP) consecutive cases of alveolar bone grafting surgery were obtained after orthodontic expansion and before alveolar bone grafting and at least 1 year postsurgery on the Hitachi MercuRay CBCT machine. The DICOM files were imported into Dolphin 3D Imaging 10.5 and reoriented for consistency. The X, Y, and Z coordinates were determined for the canine cusp tip and root tip on both the cleft and noncleft sides. The direction of movement of the canine in 1 year was determined., Results: Most canines on both the cleft and noncleft sides moved incisally, facially, and mesially. Twelve percent of the canines on the cleft side appeared to require surgical exposure. Eighty percent of the canines had less than half root development at the time of bone grafting. The amount of root development did not affect the outcome in terms of eruption amount or direction., Conclusions: Most canines on both the cleft and noncleft side moved incisally, facially, and mesially.

Background and Purpose: Alveolar bone grafting remains the standard for alveolar cleft repair. Compromised oral and/or nasal closure may impede healing and result in graft failure or persistent fistulae. Incorporating acellular dermal matrix into these repairs may protect the bone graft during mucosal healing by providing an additional layer of soft tissue coverage., Methods: A retrospective review of alveolar bone grafts undertaken at our cleft-craniofacial center from 2005 to 2007 was performed. The use of acellular dermal matrix for nasal and/or oral lining augmentation was determined. A minimum 3 months' follow-up was required for inclusion. Outcomes included (1) mucosal disruption, (2) time to complete mucosal healing, (3) bone graft exposure, (4) postoperative bone graft incorporation using the Chelsea scale, and (5) canine eruption through the graft site., Results: In total, 35 patients were included. Of those, 15 patients (four girls, 11 boys; seven Veau III, eight Veau IV) received acellular dermal matrix for mucosal augmentation (five nasal, one oral, nine nasal and oral lining). Average age at surgery was 10 years (range, 9 to 16 years). Average follow-up was 23 months (range, 3 to 35 months). Mucosal disruption occurred in 20% of the acellular group and in 30% of the control group (p=nonsignificant). Complete mucosal healing was achieved at an average of 4 weeks (range, 1 to 14 weeks) in the acellular dermal matrix group versus 4 weeks (range, 2 to 11 weeks) in the control group (p=nonsignificant). Exposure of bone graft occurred in 0% of the acellular dermal matrix group and in 30% of the control group (p=.016). The Chelsea scale demonstrated no significant radiographic difference in postoperative bone graft incorporation between the acellular dermal matrix and control groups. Canine eruption through the graft site was similar for both groups., Conclusions: These data support the conclusions that using acellular dermal matrix to augment nasal/oral mucosal lining in alveolar bone grafts (1) does not increase mucosal disruption or time to complete healing, (2) prevents postoperative bone graft exposure, and (3) appears to have no negative effect on postoperative bone graft incorporation or canine eruption through the graft site.