Long-term outcome of secondary alveolar bone grafting in cleft lip and palate patients: A 10-year follow-up cohort study

Abstract

The objective was to assess the long-term outcome of secondary alveolar bone grafting (SABG) in cleft lip and palate patients and to examine relationships between preoperative and postoperative factors and overall long-term bone graft success. The records of 97 patients with cleft lip and palate, who had secondary alveolar bone grafting of 123 alveolar clefts, were examined. Interalveolar bone height was assessed radiographically a minimum of 10 years after grafting using a 4-point scale (I–IV), where types I and II were considered a success. After an average follow-up of 16 years after SABG (range = 10.2–22.7 years), 101 of the 123 grafts (82%) were categorised as successes. Mean age in the success group was 12.1 years and 13.6 years in the failure group (p = 0.03). It was found that the success rate was significantly lower (p = 0.02) if SABG was performed after eruption of the tooth distal to the cleft. No significant differences were found with regard to the other parameters investigated. The timing of secondary alveolar bone grafting is critical with regard to the age of the patient and the stage of eruption of the tooth distal to the cleft.     

Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract

This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16–19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16–19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16–19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

The influence of the Tübingen soft palate plate and early cleft closure on the nasopharyngeal airway for the management of airway obstruction in an infant with Pierre Robin sequence: A case report

INTRODUCTIONA Tübingen palate plate and early cleft closure for successful airway management is described in a newborn with Pierre Robin sequence.PRESENTATION OF CASEA three-day-old newborn with an acute airway obstruction underwent primary treatment with a Tübingen soft palate plate.DISCUSSIONAfter stabilization of the airway, the cleft soft palate was closed after three months.CONCLUSIONThe Tübingen soft palate plate proved to be a very satisfactory treatment for the infant.     

Facial clefts involving the midline in combination with intracranial anomalies: Case studies illustrating surgical treatment and medical substitution

Abstract

Malmö and Uppsala have been regional centres for the treatment of cleft lip and palate since the beginning of the 1950s. We have about 80 new cases every year and most patients have conventional oronasal clefts, either cleft lip and palate or isolated cleft palate. During a 10-year period we have come across four patients who have had varying degrees of midface dysplasia combined with intracranial anomalies. One child died at an early age, but the other three children were given medical substitution of hypopituitarism and have had their clefts reconstructed.     

Primary,Early Bone Grafting in Complete Clefts of the Lip and Palate: A Follow-up Study of 53 Cases

Fifty-three patients with complete unilateral and bilateral cleft lip and palate between the ages of 5 1/2 and 13 1/2 years have been followed up. Following preoperative jaw orthopedic treatment, when indicated, these cases were operated with lip closure and bone grafting with four mucoperiosteal flaps as described by Nordin (1960) and Bäckdahl & Nordin (1961). In the 14 bilateral cases this operation was done in two stages, one side at a time, in this series. At the follow-up, facial appearance, hearing, speech assessment, some facial angles and incidence of crossbites were examined. In the 39 unilateral cleft cases, 80% had an acceptable appearance while 20% needed secondary surgery of the lip and nose as rated independently by four doctors. In the 14 bilateral cases 50% needed secondary operation of the lip and nose. Speech assessment in the bone-grafted group was good or superior to that in a non-bone-grafted group of patients with clefts of the primary and the secondary palate. Open nasality and consonant articulations were also taken into consideration. No permanent hearing impairment was noted in these patients although they are prone to chronic ear diseases. No serious maldevelopment of the facial skeleton was noted in our study following primary, early bone grafting. The incidence of crossbite was comparatively low. This type of treatment is continuing at our centre since the results are promising. Comparison of similar studies from other centres with long-term follow-ups are called for.     

Craniofacial development in children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes. I. Maxillary development.

Lateral skull radiographs of 85 patients with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes were compared at three different ages regarding maxillary development. Regimes that included primary bone grafting to the alveolus at six months of age resulted in inhibited anterior maxillary growth and reduced maxillary inclination. Regimes that included secondary bone grafting after eruption of the incisors but before the eruption of the canines, resulted in better maxillary development, but were not as good as regimes that omitted bone grafting altogether.     

A Follow-Up Study of Cleft Children Treated with Primary Bone Grafting: I. Orthodontic Aspects

The effect of primary bone grafting in the treatment of complete clefts has been studied with roentgenologic and biometric methods. The material, operated on during 1958–64, consisted of 16 patients with complete bilateral cleft lip and palate and 37 cases with complete unilateral cleft lip and palate. All of the studied bone grafts (= 69) healed well, but this did not lead to the expected normalisation of the growth of the middle face. On the contrary, our patients developed a pronounced maxillary retrognathia, which seemed to increase with age. This resulted in a concave facial skeletal profile for both the bilateral and unilateral cases. The occlusal analysis also indicated a maxillary growth retardation. Thus, our patients revealed a much higher frequency of anterior as well as lateral crossbites, when compared with other studies on not-bone-grafted clefts. Also, our patients had increased frequency of Class III molar relations while fewer had Class I and Class II relations. The growth aberration in many cases reached such a degree that the primary bone grafting of further cleft patients was discontinued.     

Early cleft lip repair in children with unilateral complete cleft lip and palate: a case against primary alveolar repair

All children with complete unilateral cleft lip and palate will develop some degree of malocclusion regardless whether the alveolar cleft is repaired primarily or bone grafting is deferred. To evaluate the impact of early gingivoperiosteoplasty on occlusal relationships, dental models were obtained in 5-year-old patients who underwent early cleft lip and palate repair with primary boneless bone grafting (Skoog's method) (56 children) and without alveolar intervention (51 children). The Goslon's occlusion grading system was applied to evaluate occlusal relationships in both groups. Patients with early surgical intervention to repair alveolar cleft demonstrated poor occlusal relationship with the Goslon score 4 and 5, which will likely need an orthognathic corrective procedure (50% vs. 19.6% in patients without early primary dissection of the alveolar process). Results reaffirm that an inclusion of the alveolar process into the early primary lip repair adds to the severity of occlusal maldevelopment.     

Craniofacial development in children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes. III. The soft tissue profile at 16-18 years of age.

The soft tissue profiles of 85 16-18 year old children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes were studied using lateral skull radiographs. Regimes that included secondary bone grafting to the alveolus in the mixed dentition gave better convexity of the soft tissue profile (excluding the nose) and better soft tissue sagittal jaw relationships compared with treatment regimens that included primary bone grafting. The soft tissue profile in regimes that excluded bone grafting was almost as favourable as those in regimes in which bone grafting was done during the mixed dentition.     

Craniofacial development in children with unilateral clefts of the lip, alveolus, and palate treated according to three different regimes. Assessment of nasolabial appearance.

From extraoral photographs taken from the front and in profile of 61 16-year old children with unilateral cleft lip, alveolus, and palate (UCLAP) who had been treated by three different treatment regimes, the nasolabial appearances were assessed by a panel. The photographs were masked, leaving only the mid face including the nose and lips. The following features were assessed using a five point scale: nasal form, symmetry of the nose, vermilion of the upper lip, shape of the vermilion border, total symmetry of upper lip, and nasal profile including the upper lip. The number and type of secondary operations required were recorded. Intraobserver reliability was good but interobserver agreement was poor, some observers systematically scoring more severely than others. A panel of six was therefore set up to establish an acceptable mean assessment. The treatment regime that included secondary bone grafting, and the one that included primary bone grafting and presurgical orthopaedic-T-traction, scored better on all features assessed compared with the group that underwent primary bone grafting but no T-traction. The latter group required fewer secondary revisionary procedures, however, which could explain these results.     

Use of Titanium Dental Implants as an Integrated Part of a CLP Protocol

The problem of edentulousness in the cleft area of patients with cleft lip and palate was formerly resolved with a conventional fixed bridge construction, but this approach did not always prove optimal. Nowadays, in these patients the bridge can be substituted by a crown on an osseointegrated titanium implant fixture. The concept of dental rehabilitation using titanium implants has gradually merged into our routine treatment for patients with cleft lip and palate. In this report we describe our surgical technique using osseointegrated titanium implants and evaluate our result in patients with cleft lip and palate. Sixteen patients with cleft lip and palate, 11 men and five women, were divided into two groups: group 1 consisted of six patients who did not need bone grafting prior to the fixture installation, and group 2 comprised 10 patients who had additional bone grafting three months before the fixture installation. Abutments were applied six months after fixture installation. Dental crowns and fixed bridges were then constructed. All patients were seen on regular follow-up visits. Routine roentgenograms were obtained preoperatively and when the abutments were applied. Photographs were taken at these occasions and also after the prosthodontic work was completed. Of a total of 31 fixtures, all except two were osseointegrated at the time of the abutment connection, and the remaining 29 have all been functional during the observation period, giving a success rate of 93%. In group 1 all fixtures (100%) were osseointegrated. The non-integrated fixtures were found in group 2 giving a success rate of 91% in this group. The mean follow-up time after fixture installation was six years and three months, and the mean observation time with loaded fixtures was five years and six months.     

Direct gingivoperiosteoplasty with palatoplasty

Gingivoperiosteoplasty creates a mucoperiosteal bridge across the alveolar cleft associated with cleft lip and palate. The subperiosteal tunnel allows for bone generation in the absence of bone grafting in young patients. The original procedure required wide maxillary subperiosteal dissection and flap rotation but has since evolved along with techniques to narrow the alveolar cleft toward limited dissection and direct closure. Multiple studies reveal superior facial growth parameters, particularly vertical maxillary growth, when compared with primary bone grafting typically performed within the first year of life and a reduced need for later secondary bone grafting. Most centers that perform gingivoperiosteoplasty do so in conjunction with primary lip closure after initial narrowing of the cleft with presurgical orthopedics. We present our method of direct gingivoperiosteoplasty performed simultaneously with palatoplasty after alveolar cleft narrowing without presurgical orthopedics via a two-stage lip repair. Preliminary data suggest bone growth capable of supporting tooth eruption without significant growth disturbances in a majority of patients treated with this protocol.     

扩弓后单侧完全性牙槽突裂的骨移植修复

目的:研究单侧完全性牙槽突裂畸形患者扩弓后骨移植修复的效果,为唇腭裂序列治疗后期正畸和正颌外科治疗提供临床基础。方法:对23例恒牙期单侧完全性唇腭裂术后伴发牙弓狭窄的牙槽突裂畸形患者进行快速扩弓并保持半年后,采用自体髂骨松质骨颗粒移植修复进行研究,对术后随访的X线片进行效果评价。结果:临床应用该方法治疗23例牙槽突裂患者,术后随诊3个月以上,临床观察牙槽突裂已修复,X线片显示骨密度接近正常骨质,移植骨块清晰可见,有较好的术后愈合效果。结论:正畸扩弓技术牙槽突裂骨移植修复术是唇腭裂序列治疗的重要组成部分,对于矫治伴有牙槽突裂的上牙弓缩窄畸形的唇腭裂患者,应在植骨手术前行扩弓治疗。     

Closure of large oronasal fistulas at the time of secondary bone grafting in patients with cleft lip and palate

Oronasal fistulas often arise after repair of the palate in patients with cleft lip and palate. Those located adjacent to the residual cleft are commonly closed at the time of secondary bone grafting. However, it is not easy to close larger fistulas. We present a method of closing large oronasal fistulas in the anterior palate that are adjacent to the residual cleft at the time of secondary bone grafting, which consists of reducing the size of the inferior nasal turbinate.     

Risk factors leading to mucoperiosteal flap necrosis after primary palatoplasty in patents with cleft palate

Background: Few studies have been published reporting risk factors for flap necrosis after primary palatoplasty in patients with cleft palate. This complication is rare, and the event is a disaster for both the patient and the surgeon. This study was performed to explore the associations between different risk factors and the development of flap necrosis after primary palatoplasty in patients with cleft palate.

Methods: This is a case-control study. A 20 years retrospective analysis (1994–2015) of patients with nonsyndromic cleft palate was identified from medical records and screening day registries). Demographical and risk factor data were collected using a patient´s report, including information about age at surgery, gender, cleft palate type, and degree of severity. Odds ratios and 95% confident intervals were derived from logistic regression analysis.

Results: All cases with diagnoses of flap necrosis after primary palatoplasty were included in the study (48 patients) and 156 controls were considered. In multivariate analysis, female sex, age (older than 15 years), cleft type (bilateral and incomplete), and severe cleft palate index were associated with significantly increased risk for flap necrosis.

Conclusions: The findings suggest that female sex, older age, cleft type (bilateral and incomplete), and severe cleft palatal index may be associated with the development of flap necrosis after primary palatoplasty in patients with cleft palate.     

Closure of large oronasal fistulas at the time of secondary bone grafting in patients with cleft lip and palate.

Oronasal fistulas often arise after repair of the palate in patients with cleft lip and palate. Those located adjacent to the residual cleft are commonly closed at the time of secondary bone grafting. However, it is not easy to close larger fistulas. We present a method of closing large oronasal fistulas in the anterior palate that are adjacent to the residual cleft at the time of secondary bone grafting, which consists of reducing the size of the inferior nasal turbinate.     

Secondary alveolar bone grafting: An outcome analysis

OBJECTIVE

To review the outcome of secondary alveolar bone grafting in unilateral and bilateral cleft lip and palate.

DESIGN

A surgeon’s experience, by retrospective chart review, of 70 consecutive patients at a tertiary care centre.

OUTCOME MEASURE

Periapical radiographs were taken at least six months after secondary alveolar bone grafting. The Enemark grading system was used to stratify graft-take.

RESULTS

In unilateral clefts, 33% were level 1, 36% were level 2, 20% were level 3 and 11% were level 4. In bilateral clefts, 29% were level 1, 50% were level 2, 14% were level 3 and 7% were level 4. There was no statistically significant difference between the level of take and the type of cleft. Complications encountered were infection (n=3), fistula (n=3), pain (n=4) and bone graft exposure that led to failure (n=2). Two patients required reoperation for bone grafting.

CONCLUSIONS

The iliac crest is a good donor site with excellent results and minimal morbidity.     

Late management of cleft lip and palate problems: a joint orthodontic/surgical approach

Three patients are presented from a larger case series of adolescent cleft lip and palate patients to illustrate a combined approach to the treatment of severe facial and dentoalveolar discrepancy. The following treatment regime was employed: orthopaedic expansion of the maxillary dentoalveolus; tertiary bone grafting of the alveolar cleft; upper and lower dental arch alignment and decompensation; and orthognathic surgery to correct the skeletal defect by means of a maxillary single unit advancement. The advantages of tertiary grafting (when secondary grafting has not been carried out) in the orthodontic and surgical management of these patients is discussed.     

Comparison of growth results in patients with unilateral cleft lip and palate after early secondary gingivoalveoloplasty and secondary bone grafting: 20 years follow up

The Milan surgical protocol from 1988 has included repair of lip, nose, and soft palate at 6–9 months of age, and closure of the hard palate and alveolus with an early secondary gingivoalveoloplasty at 18–36 months. The goal of this study was to evaluate the long-term maxillary growth in patients with unilateral cleft lip and palate (UCLP) who had had the early secondary gingivoalveoloplasty, compared with the growth in a sample treated before 1988, by the same surgeon, with a surgical protocol that differed only by the method and the timing of alveolar closure. In the second group they were repaired by secondary bone grafting. The samples consisted of lateral cephalograms of the UCLP early secondary gingivoalveoloplasty sample (15 patients with a mean age of 18 (1.2) years) and of the UCLP bone graft sample (10 patients with a mean age of 19 (1.1) years). The early secondary gingivoalveoloplasty patients showed that maxillary growth was inhibited compared with the secondary bone graft group. Although the early secondary gingivoalveoloplasty allowed for early repair of the alveolus together with palatal repair, eliminating the need for secondary bone grafting, it seemed to have an inhibiting influence on maxillary growth that increased the need for Le Fort I osteotomies. Even with a Le Fort I osteotomy, the early secondary gingivoalveoloplasty allows the total number of operations to be kept down to three, as in most European protocols.     

Maxillary Dental Arch and Occlusion in Patients with Repaired Clefts of the Secondary Palate

Abstract

Maxillary morphology and dental occlusion were studied from infancy to age 10 years in 32 patients born with isolated cleft palate. Wardill-Kilner push back repair of the palate had been done at a mean age of 7.5 months. Measurements obtained from casts of the jaws showed that the average maxillary dimensions before as well as after operation were less than those reported for children without clefts. The mean reduction was similar whether the cleft reached into the hard palate or affected the soft palate only. Preoperative anterior maxillary arch width in particular, and also distance from scar line to selected teeth seemed to influence postoperative development of the maxillary dental arch in individual patients.