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Objectives: To develop a reproducible, reliable clinical index of alveolar bone grafting (ABG) outcome based on the eruption position of the cleft canine tooth and determine the association between eruption position and radiographic outcome at 6 months post-grafting., Methods: Children with complete, non-syndromic, unilateral/bilateral cleft lip and palate in the West of Scotland were identified. Post-ABG radiographic outcome (Kindelan index) and canine eruption position in children with a cleft of the alveolus who had undergone ABG were documented. A Kindelan score was assigned to the 6-month post-bone-graft radiograph. Following canine tooth eruption, four-point clinical index scale (CIS) scores were assigned to maxillary occlusal images taken prior to commencement of definitive orthodontics; 1-canine eruption in alveolar crest, 2-canine eruption buccal to alveolar crest, 3-canine eruption palatal to alveolar crest, and 4-canine impaction. Intra and inter-rater reliability was assessed using Cohen and Fleiss kappa's, respectively. Duration of orthodontics treatment, number of orthodontic clinic visits, and clinical management of the cleft site space were noted., Results: Eighty-three patients representing 98 bone graft sites were identified. CIS scoring intra- and inter-rater reliability was 0.69-0.99 and 0.63-0.75, respectively. CIS score was associated with reduced visits (P = .015), months in orthodontics (P = .009), and likelihood of space closure (P = .006)., Limitations: This is a retrospective study with small numbers but is comparative to other similar studies in the literature., Conclusions: The CIS presented appears to be a reliable index of ABG outcome. It also demonstrates an association with the burden of orthodontic care post-cleft alveolar bone graft., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objectives: The aim of this study was to investigate whether a low-dose cone-beam computed tomography (CBCT) protocol provides diagnostically acceptable image quality for assessing bone healing after alveolar bone grafting., Material and Methods: The study cohort comprised 11 patients (aged 7-14 years) with orofacial clefts who had undergone alveolar bone grafting at Skåne University Hospital in Malmö, Sweden. During the postsurgical follow-up at 6 months, each patient was assessed twice: once with a standard-dose CBCT protocol and once with a low-dose CBCT protocol, which in total corresponds to one CBCT examination made with the exposure settings recommended by the manufacturer. Among others, the assessed parameters included subjective image quality, as well as bone graft height, thickness, and integration., Results: No significant differences were found between the standard- and low-dose protocols for most parameters (p > 0.05). Exceptions included subjective image quality (one observer, p = 0.05) and confidence levels during the assessment (three observers, p = 0.01, 0.01, 0.02)., Conclusions: The low-dose protocol yielded adequate image quality for postoperative CBCT healing assessment in patients who have undergone alveolar bone grafting. However, the confidence level of observers during the assessment with the low-dose protocol was reduced. This study is registered on ClinicalTrials.gov (NCT06395077)., Clinical Trial Registration: This study is registered on ClinicalTrials.gov (NCT06395077)., (© 2024 The Author(s). Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.)

Objective: Cleft lip and palate are the most common congenital malformations in the craniofacial region, occurring at a rate of 1:700 births in Brazil. These conditions lead to functional impacts on patients, such as changes in breathing, teeth, speech, chewing, swallowing and sucking. Treatment begins with primary surgeries, including lip and palate repair, which aim to reconstruct the soft tissues. Secondary alveolar bone grafting (SABG) reconstructs the bone defect in the cleft region, with the main goal of supplying bone tissue to the cleft region and restore the continuity of the alveolar process. To measure the changes in cross-sectional areas (CSAs) and nasal volume in patients and their impact on the nasal cavity (NC) in the two-month postoperative period (PO2M)., Methodology: This study included 15 patients with complete unilateral cleft lip and palate (U/CLP) indicated for alveolar bone grafting (ABG). Cone beam computed tomography scans obtained prior to SABG and at PO2M were compared. Nasal volumes and CSAs were measured by marking the masks delimiting the nasal cavity on CT scans using Mimics™ software., Results: NC volumes (total, right and left sides) were statistically lower at PO2M in patients with left-sided UCLP. In right-sided UCLP, these volumes were only significant for the total NC and left NC. The CSAs of the internal nasal valve in both groups showed significantly lower values compared to the preoperative period (p≤0.05)., Conclusion: In the short term, alveolar bone graft surgery reduces the volume of nasal cavities and the cross-sectional areas of the right and left internal nasal valve as a whole, not only the cleft area where the graft material was placed.

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.

Purpose: This preliminary study aimed to assess the efficacy of zygomatic buttress bone grafting for nasal floor augmentation in patients with a unilateral alveolar cleft who were referred after the optimal timetable for this surgery had elapsed., Case Series: Five patients, aged 12-18 years, with unilateral alveolar clefts were treated at Qaem Hospital, Mashhad, Iran. Initially, a mucous layer was established on the side of the cleft nose, followed by forming a bony bridge between the defect's sides through a bone graft derived from the zygomatic buttress and xenograft bone powder. Subsequently, the grafted region was covered with an absorbable collagen membrane, and the oral-side flap was sealed. Post-operative follow-ups occurred at 1 week, 1 month, and 3 months, and cone beam computed tomography (CBCT) was performed 6 months post-treatment. Discrepancy between the anterior edge height of the pyriform aperture on the healthy and cleft sides post-grafting was assessed. The average disparity between the height of the anterior edge of the pyriform aperture on the healthy side and the peak height achieved post-grafting on the cleft side was 1.90 ± 2.82 mm., Conclusion: Within the limitations of the study, it seems that zygomatic buttress is applicable for late unilateral alveolar bone grafting as an intraoral source, and is helpful in symmetric bony nasal floor reconstruction, with a good success rate., Competing Interests: Declaration of competing interest The authors declare no potential conflicts of interest concerning the research, authorship, and/or publication of this article., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

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.

In this study, we aimed to provide guidance for selecting bone grafting materials in cases of alveolar clefts. Twenty-nine patients with unilateral complete alveolar clefts were categorized into three groups based on the bone grafting material used: Group A (iliac bone block grafts), Group B (iliac cancellous bone grafts), and Group C (chin bone block grafts). Cone-beam computed tomography (CBCT) data were analyzed using Mimics 19.0 software. Results showed that Group A had the highest bone formation rate, with significant differences observed between Groups A and B, as well as between Groups B and C. Group A and Group C had the highest proportion of Type I in volume assessment, while Group B had the highest proportion of Type III, Significant differences were observed in the distribution of volume assessment scores among the three groups. Bone height measurement results indicated that buccal-side measurement points had a higher proportion of Type I bone height than palatal-side measurement points. Bone width measurement results showed that Type I bone width was highest in Group C, while Type IV bone width was highest in Group B. Significant differences were observed in the distribution of implanted bone width among the three groups. Total grafting scores indicated that Types A and D were predominant in Groups A and C, while Group B had the highest proportion of Type D. Significant differences were observed in the distribution of total grafting scores among the three groups. The comprehensive evaluation method provides accurate assessment of alveolar cleft bone grafting outcomes and is applicable in clinical settings. Based on the results, we consider both iliac bone blocks and chin bone blocks as suitable materials for alveolar cleft bone grafting. Grafting material selection should consider preoperative gap volume measured using CBCT, required bone quantity, donor site complications, and overall clinical needs., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

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.

Background: In patients with cleft lip and palate (CLP), secondary alveolar bone grafting (SABG) with particulate cancellous bone marrow (PCBM) is recommended. Objective: To compare bone graft outcomes in patients with unilateral CLP, when SABG is completed before or after canine tooth eruption (ACE or BCE), as measured by cone beam computed tomography (CBCT). Methods: Patients were allocated into two cohorts, ACE and BCE. The outcomes were evaluated using CBCT, followed by univariate and multifactorial analyses. Results: A total of 468 patients (age 11.61 ± 4.03 years; male/female 288/180) were analyzed, including 282 in the BCE group (9.41 ± 1.59 years, 175/107) and 186 in the ACE group (14.95 ± 4.31 years, 113/73). Although 5-level assessment revealed no significant difference in clinical success rate (>4 points) between the BCE and ACE groups (53.90% vs. 47.85%, p  = 0.20), BCE group showed significantly higher rate of bone bridges formation (73.05% vs. 62.90%, p  = 0.02), which can be attributed to variations in orthodontic participation and follow-up time. Independent predictors of graft failure were wide cleft, severe oronasal fistula, no palatal bone wall, and insufficient PCBM filling ( p  < 0.01). Conclusions: SABG should be performed before canine eruption with more aggressive PCBM filling and oral fistula management.

Background: Significant discrepancies exist in the reported variables influencing alveolar bone graft outcomes. The purpose of this study was to evaluate graft success and identify outcome predictors in a large patient cohort using an objective cone beam computed tomography assessment tool., Methods: Consecutive patients with cleft lip/palate who underwent alveolar bone grafting by 1 surgeon were included. Predictor variables were age at graft, oronasal fistula, canine position, concurrent premaxillary osteotomy, size of cleft, presence of bony palatal bridge, history of failed graft, location of primary repair, and surgeon experience. The outcome variable was graft success, determined using a cone beam computed tomography assessment tool and defined as a score of 3 or 4 (out of 4) in the following domains: vertical bone level, labiopalatal thickness, and nasal piriform symmetry., Results: The sample included 900 alveolar cleft sites (median graft age, 9.9 years). The success rate was 94.6%. Presence of an erupted canine, large cleft defect, or premaxillary osteotomy were independent predictors of graft failure; presence of a bony palatal bridge was associated with graft success ( P < 0.05)., Conclusions: Presence of an erupted canine, large bony defect, or premaxillary osteotomy increase the risk of failure, and a bony palatal bridge portends success. Age 12 years or older, visible oronasal fistula, history of failed graft, primary cleft repaired at outside institution, and surgeon experience were associated with higher graft failure, but were not independent predictors when controlling for covariates. Surgeons should be aware that these factors in combination increase the odds of graft failure., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons.)

The secondary alveolar bone grafting procedure is typically recommended during the late mixed dentition phase, prior to the eruption of the permanent canine, in patients with cleft lip and palate. The anatomical and functional adaptations observed in the grafted area allow spontaneous migration and eruption of the adjacent maxillary canine. An alveolar bone graft can be performed using autogenous bone or recombinant human bone morphogenetic protein-2 (rhBMP-2). Employing rhBMP-2 in a collagen membrane eliminates the need for a donor site, thus reducing surgical morbidity. This paper aims to present a case involving complete orthodontic rehabilitation with a three-year follow-up of a male patient with a unilateral complete cleft lip and palate, posterior and anterior crossbite, where grafting was performed with rhBMP-2 at a single centre. Orthodontic intervention began at 8 years of age with rapid maxillary expansion, followed by facemask therapy. The alveolar bone grafting procedure was performed using rhBMP-2 in a collagen membrane, according to the surgical protocol developed by the Oslo team. Comprehensive orthodontic treatment started 15 months post bone grafting, during which the maxillary permanent lateral incisor distal to the alveolar cleft was successfully moved mesially into the grafted region. This intervention resulted in adequate occlusal and periodontal outcomes. The alveolar graft with rhBMP-2 produced adequate and stable alveolar bone formation, facilitating tooth eruption, orthodontic movement, and stability at the cleft site., (Copyright © 2024 CEO. All rights reserved.)

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.

The purpose of this study was to compare the efficiency of using autologous platelet-rich fibrin versus a resorbable collagen membrane in secondary alveolar bone grafting. Patients were randomly allocated to the three treatment groups: Group 1 - twelve children in whom the nasal layers of the alveolar clefts were repaired using autologous platelet-rich fibrin with autogenous chin bone; Group 2 - twelve children in whom the nasal layers of the alveolar clefts were repaired using bovine collagen membrane type I (Colla-D) with autogenous chin bone; and Group 3 - twelve children in whom the bony alveolar clefts were grafted with autogenous chin bone after construction of a watertight nasal floor had been completed. The study population comprised 36 patients with alveolar clefts, ranging in age from seven to 12 years. At the last follow-up period all groups had stable healing conditions and good radiological outcomes in terms of the alveolar bone height bordering the teeth (both mesially and distally) and the incorporation of grafting material with the surrounding bone. The use of either a PRF membrane and a collagen membrane as an interpositional layer between the nasal layer and the autogenous chin bone graft enhanced bone formation and density in alveolar clefts compared with the control group., (Copyright © 2024 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

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.

The aim of this systematic review was to compare the effectiveness of pre-alveolar bonegraft (ABG) orthodontics with no orthodontic treatment for patients with non-syndromic unilateral cleft lip, alveolus and palate. All relevant studies from 1946 to October 30, 2022, were identified using several sources including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, Scopus, EMBASE, MEDLINE (Ovid) and EPUB ahead of publications and non-indexed citations. Randomized Controlled Trials (RCT) and Controlled Clinical Trials (CCT) were included., Population: Non-syndromic complete unilateral cleft lip, alveolus and palate patients who have had ABG surgery., Intervention: Orthodontics prior to ABG. Comparison: No orthodontic treatment prior to ABG., Primary Outcome: Successful eruption of permanent canines. All articles were screened for the title, abstract and full text independently and in duplicate by 2 reviewers. The quality assessment of RCT was performed using Cochrane's risk of bias tool and the CCT was assessed using ROBINS-I tool. Of the 904 studies retrieved in the search, one RCT and one CCT were included. Both studies were judged as high risk of bias. The results from one study showed a statistically significant increase in bone volume and decreased bone defect post-ABG in the orthodontic treatment group. However, there was no difference with respect to other variables. Both included studies were of low quality. There is not enough evidence to recommend orthodontic treatment pre-ABG for patients with complete unilateral cleft lip, alveolus and palate. Future high-quality studies are required to inform patients and clinicians about the effectiveness of pre-graft orthodontic treatment., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: The present study aims to quantitatively assess secondary alveolar bone graft (SABG) resorption in unilateral cleft lip, alveolus and palate (UCLAP) patients in a 2-3 year longitudinal follow-up setting by using a validated 3D protocol. Furthermore, the potential relation of SABG resorption with maxillary canine position and a number of patient-related factors was investigated., Methods: UCLAP patients who underwent SABG and had good quality CBCT images at the following timepoints were included in the study: pre-operative (T0), immediate (T1), 6 months (T2) and either 1-2 years (T3) or 2-3 years (T4) post-operative. The final bone grafted region was defined on the T1 scans and refined in the registered T0 scans. The bone graft after resorption was determined by applying threshold-based segmentation on the registered T2, T3 or T4 scans within the segmented bone graft volume. The position of the canines was determined at every timepoint at the cleft and non-cleft side., Results: Forty-five UCLAP patients (mean age 9.0 ± 1.3 years) were included. In the first 6 months after SABG, 43.6% bone resorption was recorded. 2-3 years post-operative, 56% bone resorption was found if the maxillary canine was not yet erupted and 42.7% if it erupted through the graft. The vertical position of the canines was significantly higher on the cleft side at T3., Conclusions: The present study reports significant SABG resorption over time. However, no correlation was found between SABG resorption and canine position, nor between other patient-related factors., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

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.)

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.

Background: Several methods have been proposed to assess outcome of bone-grafted alveolar clefts on cone beam computed tomography (CBCT), but so far these methods have not been compared and clinically validated., Objectives: To validate and compare methods for outcome assessment of bone-grafted clefts with CBCT and provide recommendations for follow-up., Methods: In this observational follow-up study, two grading scales (Suomalainen; Liu) and the volumetric bone fill (BF) were used to assess the outcome of 23 autogenous bone-grafted unilateral alveolar clefts. The mean age at bone grafting was 9 years. The volumetric BF was assessed in five vertical sections. The bone-grafted cleft outcome was based on a binary coding (success or regraft) on a clinical multidisciplinary expert consensus meeting. Grading scales and volumetric assessment were compared in relation to the bone-grafted cleft outcome (success or regraft). Reliability for the different outcome variables was analyzed with intra-class correlation and by calculating kappa values., Limitations: The study had a limited sample size. Clinical CBCT acquisitions had a varying tube current and exposure time., Results: Volumetric 3D measurements allowed for outcome assessment of bone-grafted alveolar clefts with high reliability and validity. The two grading scales showed highly reliable outcomes, yet the validity was high for the Suomalainen grading scale but low for the Liu grading scale., Conclusions: Volumetric 3D measurement as well as the Suomalainen grading can be recommended for outcome assessment of the bone-grafted cleft. Yet, one must always make a patient-specific assessment if there is a need to regraft., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Orthodontic Society.)

Purpose: The aim of this study is to assess the effectiveness of maxillary cortical bone graft chips harvested by bone scraper, covered with platelet-rich fibrin (PRF) in alveolar clefts., Patients and Methods: Seventy-two cleft patients were examined for their eligibility to be part in this comparative study; they were randomly divided into group A, thirty-six patients had received cancellous bone chips from iliac crest; group B, thirty-six had received cortical bone chips harvested from maxilla using a curved bone scraper, covered with PRF. The clinical success over the follow-up period was evaluated on the basis of elimination of the oronasal fistula, radiographic assessment of bone graft volume, achievement of the osseous continuity of the alveolar arch, and the extent of the vertical bone height., Results: The mean of volume gained in group A was 0.8053 ± 0.9682, while for group B was 0.7397 ± 0.7703. The amount of vertical bone loss between groups was registered, and the chi-square test revealed insignificant differences between study groups (p = 0.547). The result of the frequency of fistula development after grafting in both groups was insignificant (p = 0.074). Also, for the continuity of the maxilla as a one piece, the results were insignificant differences between study groups (p = 0.058)., Conclusion: In conclusion of our study, intraoral harvesting of maxillary cortical chips by bone scraper covered with PRF is able to achieve a valid functional and aesthetic support in alveolar cleft patients, meeting the reconstructive goals., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

To retrospectively review the clinical effect of comprehensive treatment of alveolar cleft (CTAC) using the mandible as the bone source. Patients with alveolar clefts who met the inclusion criteria were subjected to a CTAC protocol that included the following: (1) preoperative orthodontic treatment for creating good soft-tissue conditions; (2) 'area-like grafting' with subperiosteal osteogenic chin bone instead of cartilaginous osteogenic iliac bone; (3) simulation of normal bone anatomy via a sandwich-like bone graft consisting of 'cortical bone + cancellous bone + cortical bone'; and (4) strong internal fixation to ensure initial bone block stability. At 6 months postoperatively, the titanium plate was removed and cone-beam computed tomography was performed to evaluate the surgical results. A total of 54 patients underwent treatment with the CTAC protocol. The average age at the initial operation was 10.3 ± 2.1 years, and the average hospital stay was 2.8 ± 0.6 days. At 6 months postoperatively, 49 patients (90.7%) showed good clinical results. The transplanted bone block formed a 'cortical bone + cancellous bone + cortical bone' structure similar to that of the normal jawbone. A mature bone bridge formed, and the impacted permanent teeth continued to erupt and enter the bone graft area. CTAC is a comprehensive restorative solution for alveolar cleft repair that integrates multiple concepts, including orthodontics, embryology, anatomy, and improvements to surgical methods. The method is easy to perform, causes little surgical trauma, and shows a stable success rate, and is thus worth promoting., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Success rates for alveolar bone grafting range from 30 to 96%. There is limited information regarding the success of repeat grafts., Purpose: The purpose of this study was to determine the radiographic success rate of repeat alveolar bone grafts., Study Design: The study designs was a retrospective cohort study of patients who underwent repeat grafting by 1 surgeon over 15 years. To be included, subjects had to have: cleft lip and alveolus and a cone-beam computed tomography (CBCT) scan obtained >6 months after repeat graft. Patients were excluded if CBCT was inadequate., Predictor Variable: Predictor variables were sex, age at repeat graft, cleft type, presence of an erupted canine, premaxillary osteotomy at time of repeat graft, presence of a visible oronasal fistula, size of bony defect, presence of a bony palatal bridge, and whether the surgeon who performed the repeat graft also performed the initial graft., Main Outcome Variable: The outcome variable was graft success determined using CBCT assessment and defined as a score of >3 out of 4 in each domain: vertical bone level, labiopalatal thickness, and piriform symmetry., Covariates: The covariates were time from bone graft to CBCT (months) and age at time of CBCT (years)., Analyses: Frequency distributions, relative risk with 95% confidence intervals, medians, and interquartile ranges were calculated. Pearson c2 and Fisher exact tests were performed to determine predictors of outcome. A P < .05 was considered statistically significant., Results: Fifty subjects (54% male) who had repeat bone grafting to 59 cleft sites were included. Median follow-up time from repeat graft to CBCT was 7.0 months (interquartile range: 5.9 months). The radiographic success rate was 81.4%:91.7% if the same surgeon performed both initial and repeat grafts, but 78.7% if initial graft was completed by another surgeon (P = .43)., Conclusion and Relevance: Despite being a multifactorial issue, extensive and bilateral clefts, the presence of an erupted tooth in the cleft area, a visible oronasal fistula, and concomitant osteotomy of the premaxilla are warning signs of the possibility of failure. Performing repeat alveolar bone grafting by an experienced surgeon appears to increase the chance of success., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. All rights reserved.)

The secondary alveolar bone grafting (SABG) step restores the continuity of the alveolar bone necessary for dentition. Faced with the complications of autografts, synthetic biomaterials such as Bioglass (BG) 45S5 have been proposed. The objective was to evaluate the success rate of SABG with the addition of BG 45S5 and to highlight the prognostic factors. Patients who underwent operation between 2015 and 2021 and had follow-up cone-beam computed tomography (CBCT) were analyzed. Multivariate analysis was performed to determine factors influencing radiographic success. A total of 102 SABG were analyzed. They were unilateral total cleft lip and palate (49, 48.0%). The mean age at surgery was 9.32 ± 3.09 years. Surgeries were performed mainly outside a syndromic context and without a family history after orthodontic preparation. The radiographic success rate at 1 year was 80.4%. Mixed dentition stage (odds ratio [OR] = 7.3, p = 0.024), absence of syndromic context (OR = 20.7, p = 0.024) and female sex (OR = 4.88, p = 0.021) were factors predictive of surgical success. The use of BG 45S5 instead of autograft is relevant for SABG, with a 1-year success rate of over 80%. The stage of mixed dentition, the absence of syndromic context, and female sex were factors for good prognosis., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To review the existing evidence on the adjuvant use of autologous platelet concentrates (APCs) with iliac crest bone graft (ICBG) in the reconstruction of the secondary alveolar cleft., Methods: Electronic databases were searched systematically until November 2022. Clinical trials comparing the three-dimensional radiological outcomes of patients who underwent secondary alveolar bone grafting (SABG) with ICBG and APCs to those with ICBG alone and the radiological outcomes assessed 6 months after surgery were included. Two authors performed the study selection and the assessment of the risk of bias. Meta-analysis was performed using the random-effects model to determine the risk ratio (RR) for developing wound dehiscence and the mean difference (MD) with a 95% confidence interval (CI) for the percentage of newly formed bone., Results: Nine studies (seven RCT and two CCT) were included with a low to high risk of bias. At the 6-month follow-up, the study group revealed insignificant results regarding the percentage of newly formed bone (MD = 6.49; 95% CI: -0.97, 13.94; p = .09; χ 2  = 0.01; I 2  = 71%). In addition, the overall risk of developing wound dehiscence was lower in the study group (RR = 0.34; 95% CI: 0.15, 0.78; p = .01; χ 2  = 0.67; I 2  = 0%)., Conclusion: Currently, there is insufficient evidence to support the adjuvant use of APCs with ICBG on enhanced bone regeneration following secondary alveolar bone grafting. However, combining ICBG and APCs might be beneficial in reducing the risk of developing wound dehiscence., (© 2023 Special Care Dentistry Association and Wiley Periodicals LLC.)

During secondary alveolar cleft grafting, the use of autogenous cancellous bone harvested from the iliac crest is still considered the gold standard. Due to the risk of donor-site morbidity and excessive graft resorption, alternative grafting materials (e.g. intraoral bone, xenografts) have been tested. Autogenous tooth bone graft (ATB) is a novel material derived from extracted teeth. ATB has successfully been used in pre-prosthetic and periodontal surgery for hard-tissue reconstruction. Seven patients with unilateral cleft lip and palate were treated with ATB, using their own deciduous teeth for grafting. Defects were accessed utilizing a novel split-thickness papilla curtain flap. Cone-beam computed tomography scans were taken prior to and 3 months following cleft surgery to assess graft integration, graft stability, and the volume of the newly formed hard tissues. Hard-tissue gain, as measured at the 3-month follow-up, averaged 0.65 cm 3  ± 0.26 cm 3 . Results showed acceptable graft integration and stability at the 3-month follow-up, with no adverse effects or excessive resorption of the graft. The use of ATB might be a feasible alternative for alveolar cleft grafting. However, long-term studies using a large sample size are required to derive further conclusions., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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.

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.)

The purpose of this study was to review the existing evidence from randomized controlled trials (RCTs) on the effect of autogenous bone grafts combined with a platelet-rich concentrate on alveolar clefts. An electronic search was conducted in the PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov databases for studies published between January 2000 and April 2022. This study included six RCTs to evaluate bone quantity (bone formation ratio, %) and quality (bone density in Hounsfield units, HU), as well as complications as a way to assess the safety of the technique. Two independent reviewers assessed the risk of bias. There was no statistically significant difference in bone formation ratio at 6 months of follow-up between the use of autologous bone alone for alveolar bone grafting or adding platelet-rich plasma (PRP) (mean difference (MD) 14.33%, 95% confidence interval (CI) - 7.19% to 35.85%; P = 0.196) or platelet-rich fibrin (PRF) (MD 9.38%, 95% CI -2.36% to 21.12%; P = 0.123) to autologous bone. The MD for the change in bone density at 6 months was in favour of PRP added to autologous bone graft (MD 155.69 HU, 95% CI 99.29-212.09 HU; P < 0.001); however, this result was based on only two studies, one of which had a high risk of bias. Patients who received autologous bone graft with PRP were significantly less likely to experience complications (odds ratio (OR) 0.21, 95% CI 0.05-0.92; P = 0.038), but this was no longer statistically significant after a sensitivity test (OR 0.24, 95% CI 0.04-1.56; P = 0.138). In conclusion, this systematic review and meta-analysis appears to show no benefit to using a platelet-rich concentrate combined with autologous bone for alveolar cleft grafting in terms of bone volume, bone density, or complications., Competing Interests: Competing interests None., (Copyright © 2023 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

Background: Patients with unilateral cleft lip and palate (UCLP) undergo alveolar bone grafting (ABG) to unite the bony segments before eruption of the maxillary permanent canine., Purpose: This study assessed the frequency of canine impaction after ABG in the UCLP patient population and identified associated demographic, anatomical, and operative factors., Study Design, Setting, Sample: This retrospective cohort study included 257 patients with UCLP who received ABG surgery at a single craniofacial center., Predictor Variables: The variables were cleft characteristics, pre-ABG procedures, operative factors, and dental anomalies identified through electronic health records, radiographs, and intraoral photographs taken before ABG and at least 2 years after ABG., Main Outcome Variable: The primary outcome variable was the presence of an impacted maxillary canine, defined as malposition of a fully developed canine following ABG with full eruption of the contralateral canine., Analyses: The t tests, χ 2 tests, and logistic regression analysis were used to evaluate frequency of canine impaction and test for associations with the predictor variables., Results: Of 257 patients, 56% were male with a mean age of 9.2 years at the time of ABG. The frequency of canine impaction was 27% (n = 69, 95% confidence interval 22 to 33%). Significant associations were found for: complete clefts (30 vs 12%, P = .017), hypodivergent facial patterns (low angle: 46%; high angle: 29 vs 22% normal angle, P = .042), females (adjusted odds ratio [aOR] = 2.1, P = .015), early grafting with less than 1/3 developed canine root (aOR = 3.36, P = .024), pregraft extraction of primary canine (aOR = 2.3, P = .009) and greater permanent canine angulation (odds ratio = 1.1, P < .0001). No significant associations with pregraft orthodontic expansion or regrafting were detected., Conclusion and Relevance: In this study, about one in four patients with UCLP had an impacted canine. Multiple factors including pregraft extraction of the primary canine and increased canine angulation were associated with impaction of the permanent canine., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. 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.)

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.

Objectives: To review the effectiveness of secondary alveolar bone grafting using iliac cancellous bone in patients with unilateral complete alveolar cleft and to investigate the factors influencing it., Methods: A retrospective study of 160 patients with unilateral complete alveolar clefts who underwent iliac cancellous bone graft repair at the Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, was conducted. Eighty patients in the young age group (6-12 years) and 80 in the old age group (≥13 years) were included. Bone bridge formation was determined using Mimics software, and the volume was measured to calculate the iliac implantation rate, residual bone filling rate, and resorption rate. The factors that affected bone grafting in both subgroups were investigated., Results: Using bone bridge formation as the clinical success criterion, the success rate for the entire population was 71.25%, with a significant difference of 78.75% and 63.75% for the young and old age groups, respectively ( P =0.036). The gap volume in the latter was significantly larger than that in the former ( P <0.001). The factors that influenced bone grafting in the young group were the palatal bone wall ( P =0.006) and history of cleft palate surgery ( P =0.012), but only the palatal bone wall affected the outcome in the old age group ( P =0.036)., Conclusions: The results of alveolar bone grafting for the old age group were worse than those for the young age group. The palatal bone wall was an important factor that affected alveolar bone grafting, and alveolar bone grafting in the young patients was influenced by the history of cleft palate surgery.

A large number of older patients (≥13 y old) with alveolar clefts missed the optimal alveolar bone grafting time period in China. This study aimed to determine the accuracy and repeatability of modified computer-aided engineering subtraction for volumetric measurement of these patients. In addition, the study aimed to determine whether the volume of defect is correlated with cleft type (cleft lip and alveolus, cleft lip and palate), cleft location, age, and sex. Preoperative computed tomography data from 100 patients of unilateral alveolar cleft patients without secondary alveolar bone grafting were measured using 2 methods. The maxillary resin model around the alveolar cleft was printed using the 3-dimensional (D) printing method, and the volume of the defect was measured using the drainage method. In the modified subtraction method, Mimics software was used to simulate fracture filling by layer drawing, and the defect volume was determined by subtracting the preoperative fracture template from the filled 3D skull template. The mean time taken to calculate an alveolar cleft defect volume by modified subtraction method was 3.2 minutes. The average defect volume measured using the 3D printing and modified subtraction methods were 1.58±0.41 and 1.55±0.42 cm 3 , respectively. Findings suggest that cleft location and age do not affect the defect volume of older patients with alveolar cleft, unlike cleft type and sex. The modified computer-aided subtraction method provides good accuracy, consistency, and reproducibility in measuring alveolar ridge defect volume. Moreover, this method is more efficient and cost-effective than the 3D-printed model method., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

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.

Alveolar cleft is one of the key links of cleft lip and palate reconstruction due to its close relationship with tooth and jaw coordination and nasolabial deformity. The alveolar bone graft repairs the hole in the gum ridge and stabilizes the bone arch, providing better support for the base of the nose and new bone for the roots of the developing teeth to grow into. Unfortunately, bone graft failure in the traditional way, even among minor clefts, bony hypoplasia, or absence that affects the nasal base and piriform rim, is common. Two-stage alveolar bone grafting, which has advantages in addressing the underlying skeleton and deficiency, could be an optional surgical procedure for nasal floor reconstruction in adult patients with a broad alveolar cleft.

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.

Objectives: To investigate the osteogenic effect of allograft bone (BIO-GENE) and autologous iliac crest bone graft in the alveolar cleft repair., Materials and Methods: A total of 131 patients with congenital unilateral alveolar cleft who consulted in our hospital from January 2016 to May 2021 were selected and divided into 3 groups according to the different bone restoration materials used. Group A totaling 43 cases was the autologous bone group; group B totaling 41 cases was the BIO-GENE group; and group C totaling 47 cases was the BMP-2+BIO-GENE group. The preoperative and postoperative cone beam CT data of the same patient were imported into MIMICS 21.0 in DICOM format. The preoperative cleft volume and newly formed bone volume were calculated by 3-dimensional reconstruction to measure their osteogenic rate., Results: The differences in osteogenesis rates were not statistically significant in the group B compared with the group A, and in the group C compared with the group B ( P >0.05 for both). The differences in osteogenesis rates were statistically significant in the group C compared with the group A ( P =0.003)., Conclusions: Comparative studies found the allograft bone with an ideal artificial material to repair alveolar clefts has become possible. Meanwhile, the addition of BMP-2 in the allograft bone significantly increased the osteogenic rate., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Machine learning based auto-segmentation of 3D images has been developed rapidly in recent years. However, the application of this new method in the research of patients with unilateral cleft lip and palate (UCLP) is very limited. In this study, a machine learning algorithm utilizing 3D U-net was used to automatically segment the maxilla, fill the cleft and evaluate the alveolar bone graft in UCLP patients. Cleft related factors and the surgery impact on the development of maxilla were analyzed., Methods: Preoperative and postoperative computed tomography images of 32 patients (64 images) were obtained. The deep-learning-based protocol was used to segment the maxilla and defect, followed by manual refinement. Paired t-tests and Mann-Whitney tests were performed to reveal the changes of the maxilla after surgery. Two-factor, two-level analysis for repeated measurement was used to examine the different trends of growth on the cleft and non-cleft sides of the maxilla. Pearson and Spearman correlations were used to explore the relationship between the defect and the changes of the maxillary cleft side., Results: One-year after the alveolar bone grafting surgery, different growth amount was found on the cleft and non-cleft sides of maxilla. The maxillary length (from 34.64 ± 2.48 to 35.67 ± 2.45 mm) and the alveolar length (from 36.58 ± 3.21 to 37.63 ± 2.94 mm) increased significantly only on the cleft side while the maxillary anterior width (from 11.61 ± 1.61 to 12.01 ± 1.41 mm) and posterior width (from 29.63 ± 2.25 to 30.74 ± 2.63 mm) increased significantly only on the non-cleft side after surgery. Morphology of the cleft was found to be related to the pre-surgical maxillary dimension on the cleft side, while its correlation with the change of the maxilla after surgery was low or not statistically significant., Conclusion: The auto-segmentation of the maxilla and the cleft could be performed very efficiently and accurately with the machine learning method. Asymmetric growth was found on the cleft and non-cleft sides of the maxilla after alveolar bone graft in UCLP patients. The morphology of the cleft mainly contributed to the pre-operation variance of the maxilla but had little impact on the maxilla growth after surgery., (© 2023. The Author(s).)

The purpose of treating alveolar bone cleft is to restore a normal maxilla structure. Multiple factors have been identified that can affect the success of alveolar bone grafting. However, with consistent treatment modifications, the surgical outcomes have been improved, but alveolar bone loss still exists. Thus, a new aspect should be found to solve this problem. As alveolar bone belongs to the periodontal tissues, the mechanism of the alveolar bone loss after bone grafting in patients with alveolar bone cleft may be similar to the development of alveolar bone loss in periodontitis. Cell-free DNA (cfDNA) has been demonstrated as a key promoter of alveolar bone loss during periodontal inflammation. We hypothesized that cfDNA-related innate immune responses could be a major inducement for postoperative bone loss after alveolar bone grafting. In this perspective, we preliminarily proved the potential association between cfDNA, TLR9 pathway, and alveolar bone grafting operation, and it might verify that surgical trauma could accumulate cfDNA, which can further activate cellular TLR9 signaling., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Huang, Yang and Shi.)

Reconstruction of alveolar clefts using cancellous bone graft is associated with a high rate of resorption. The aim of this study was to evaluate the osseointegration capacity of cortical calvarial bone grafting using 3-dimensional imaging assessment for alveolar cleft reconstruction in pediatric population.All alveolar bone grafting procedures performed between January 2015 and October 2017 in the maxillofacial surgery department of Lille University Hospital were included. All patients were evaluated clinically and by 3-dimensional imaging before bone grafting and at 3 months after surgery. Cleft and bone graft volumes were assessed using Horos software, v. 3.3.5, through a segmentation process. The bone filled ratio at 3 months after surgery was calculated. A total of 48 alveolar bone grafting procedures were performed in 37 patients: 3 unilateral cleft lip and alveolar, 20 unilateral cleft lip and palate, and 25 bilateral full cleft lip and palate (3 patients had only unilateral surgery). The mean bone filled ratio was 72.27%±23.65%, 81% for unilateral cleft lip and alveolus, 75.4%±20.6 for unilateral cleft lip and palate, and 65.5%±30 for bilateral complete cleft lip and palate ( P =0.1981). Calvarial bone grafting seems to be a relevant alternative to other donor sites for alveolar cleft reconstruction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

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.

Secondary alveolar bone grafting (SABG) using autologous iliac crest cancellous bone is a standard procedure for patients with cleft lip and palate (CLP). The aim of this study was to evaluate patient satisfaction after bone grafting of the alveolar cleft. Patients who underwent SABG between 2000 and 2010 in one surgical centre were included in this cross-sectional study. Three questionnaires were used, one addressing functional and aesthetic outcomes (nine items), the second being the 14-item Oral Health Impact Profile (OHIP-G14), and the third addressing donor site morbidity. A total of 103 patients fulfilled the inclusion criteria, of whom 71 could be contacted, and 52 completed the questionnaires. The majority of the patients (98%) were satisfied with the aesthetic and functional results and reported low donor site morbidity. A significant correlation was found between scores from the patient satisfaction questionnaire and the OHIP-G14. Regarding overall patient satisfaction, the manifestation of the cleft had no significant influence. The questionnaires used allowed the assessment of subjective outcome parameters, but might not be absolutely specific and exclusive for the SABG procedure in the framework of comprehensive CLP therapy. Nevertheless, SABG using autologous iliac crest cancellous bone can be considered a highly satisfactory procedure., (Copyright © 2022 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This single-centre retrospective cohort study aimed to evaluate secondary alveolar bone grafting (SABG) and identify the factors associated with failure., Methods: Individuals born with alveolar cleft with or without cleft palate who had SABG consecutively between 2004-2006 and 2011-2013 were enrolled in this study. After the exclusion of 20 cases due to poor quality radiographs, 115 patients (50 girls and 65 boys) who had undergone 131 SABG procedures were included. According to a modification of the Bergland Scale (mBS), the alveolar bone level was assessed using occlusal films obtained 3 months after SABG. Data on factors plausible for SABG failure were collected from patient records, photographs, cast models, and presurgical occlusal radiographs. The Mantel Haenszel Chi-Square test was used to test the possible impact of these factors on the mBS scores., Results: A total failure (mBS score of 4) was observed in 9% of the cases. The alveolar bone level correlated with cleft laterality (P = 0.039), alveolar cleft extension (P = 0.033), age at SABG (P = 0.007), root developmental stage (P = 0.021), and oral hygiene (P = 0.007)., Conclusion: Secondary alveolar bone grafting failure was correlated with a bilateral alveolar cleft, absence of an initial partial alveolar bridge, higher age, increased root developmental stage, and poor oral hygiene. Efforts to achieve optimal oral hygiene are recommended to improve outcomes, particularly when SABG is performed in individuals with a bilateral cleft, increased alveolar cleft extension, or at higher ages., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

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.