A Follow-Up Study of Cleft Lip and Palate Patients Treated with Orthodontics,Secondary Bone Grafting,and Prosthetic Rehabilitation

The purpose of this study was to evaluate the significance of secondary bone grafting in cleft palate treatment. The investigation included a clinical, a biometrical, and a radiographic follow-up of the occlusion, the craniofacial morphology and the function of the masticatory system. The total material of secondary bone grafting cases during the period of 1958–68 consisted of 125 patients. For the final examination, 93 of them were present. The treatment plan was: (1) orthodontic treatment, (2) bone grafting, (3) retention treatment, (4) prosthetic reconstruction of lost teeth. 58 bridges were inserted. The mean age of the patients at the time of bone grafting was 20 years and the mean lag between the bone grafting procedure and the final check-up was 7 1/2 years. Besides bone grafting, 43 palatopharyngeal flap-operations were carried out. At the final check-up, none of the patients wear any obturator. Besides these operations 7 osteotomies of the lower jaw were carried out. The frequence of crossbites was reduced from 94 to 31%. Open bites were present in 6 cases while the remaining cases exhibited normal overjet and overbite. A slight degree of relapse after the orthodontic expansion treatment was noted; thus, in 12 cases, one or two teeth relapsed to crossbite occlusion. The jaw function was fairly normal in all cases studied. The chewing ability was reduced in 9 cases, though the average number of tooth contact-pairs increased, from 5.9 prior to orthodontic treatment to 11.4 at the final examination. The cephalometric part of the investigation indicated that the average patient had a more retrognathic type of face with steeper mandibular and nasal planes than are reported for non-clefts. The bone grafting procedure was successful in 96% of the cases, as evaluated from radiographs. The reorganisation of the average bone graft was completed within 3 to 6 months. This clinical and radiographic investigation revealed that bone grafting of the alveolar process and the palate did normalise and stabilize the maxilla in practically all instances. Thus the method used had prevented relapse after orthodontic treatment in the great majority of cases and the definitive prosthetic rehabilitation could be carried out using the same principles as in non-cleft cases.     

Assessment of secondary alveolar bone grafting using a modification of the Bergland grading system.

Although the management of the alveolar cleft remains controversial secondary alveolar bone grafting is the most widely accepted approach. The results of a series of 71 secondary alveolar bone grafts performed between 1990 and 2001 on 58 patients with complete cleft lip and palate 13 of which were bilateral are presented. Bone grafts were assessed when the canine tooth had fully erupted using periapical dental radiographs.The occlusal level of the newly obtained interdental bone of each grafted cleft was recorded and categorised in accordance with the Oslo grading system as described by Bergland. In addition the basal level of each bone graft was recorded. In this way total bone graft height was measured and each graft was categorised with respect to the desired normal height of noncleft interdental alveolar bone. This modified analysis grades more precisely the efficacy of secondary alveolar bone grafting and helps to identify and categorise those patients with insufficient bone for dental, orthodontic and orthognathic rehabilitation and those who may require further investigation and regrafting.     

New orthodontic and orthopaedic managements on the premaxillary deformities in patients with bilateral cleft before alveolar bone grafting

At the age of mixed dentition, a downward or laterally displaced premaxilla with a wide alveolar cleft in patients with bilateral cleft lip and palate remains a dilemma both for orthodontists and surgeons. These premaxillary deformities not only make the alveolar bone grafting difficult but also aesthetically and functionally unacceptable. The purpose of the present article is to introduce three new orthodontic and orthopaedic techniques for solving these premaxillary deformities and facilitating alveolar bone graft through a non‐surgical approach. These techniques are the premaxillary orthopaedic intrusion for correcting a downward displaced premaxilla, the premaxillary orthopaedic repositioning for correcting a laterally displaced premaxilla, and maxillary orthopaedic protraction by alternate rapid maxillary expansions and constrictions for minimizing a wide alveolar cleft. They were evaluated clinically and cephalometrically for their treatment effects. The results revealed that the premaxillary and cleft deformities were corrected in a short period of time and therefore the alveolar bone grafting could be carried out without difficulty in all of the patients who received the treatment. The treatment effects were mostly orthopaedic and partly orthodontic. No growth disturbance on the maxilla was observed throughout the treatment. These new orthodontic and orthopaedic techniques are very effective for solving the difficult‐to‐treat premaxillary deformities and facilitating the alveolar bone grafting in the patients with bilateral cleft.      

脱钙人牙基质在修复齿槽突裂中的应用研究

目的研究唇腭裂术后齿槽突裂植骨修复的新方法。方法2005年4月-2006年8月，采用自体髂骨松质骨混合脱钙人牙基质（decalcified denfinal matrix of human，DDM）治疗26例（30侧）齿槽突裂患儿。男16例，女10例：年龄6～12岁。单侧齿槽突裂22例，双侧4例。伴鼻翼塌陷26例，乳牙滞留5例，错位牙3例，畸形牙1例。患儿于术前、术后1周，1、2、3、6和12个月摄全口曲面断层X线片、上颌前部咬殆X线片（以裂隙侧尖牙为中心），观察骨愈合、骨吸收情况。结果术后23例患儿伤口Ⅰ期愈合，口鼻瘘严密关闭；1例双侧齿槽突裂切口感染，6个月后重新植骨；2例少量骨组织外露，予冲洗、换药、涂擦美宝湿润烧伤膏后伤口愈合。髂骨供区均Ⅰ期愈合。术后X线片可见裂隙间骨桥形成，恢复了颌骨的连续性和稳定性。4例6～9岁患儿平均观察6．5个月，22例9～12岁患儿平均观察8．6个月。根据术后3个月X线片，采用Bergland等评价标准进行疗效分级，Ⅰ级16例16侧（53．3％），Ⅱ级7例8侧（26．7％），Ⅲ级2例4侧（13．3％），Ⅳ级1例2侧（6．7％）。植入骨成活率为93．3％，临床成功率为80％。结论采用DDM联合髂骨松质骨修复齿槽突裂，能减少骨吸收，是一种新骨形成的加速剂，骨生成潜能好、骨诱导明显，临床成功率高。     

Secondary bone grafting and orthodontic treatment in patients with bilateral complete clefts of the lip and palate

The results of secondary bone grafting and orthodontic treatment in 41 patients with bilateral complete clefts of the lip and palate are reported. Good bone formation was found in 98% of the cleft sites grafted before the eruption of the canines, and in 80% of the clefts grafted later. Closure of both cleft spaces by orthodontic means was achieved in 20 of the 21 patients in the first group, and in 14 of the 20 patients in the second group. The bone grafts failed in one cleft site in 4 patients, all of which were regrafted with satisfactory results. In 2 patients one of the canines was later affected by external root resorption, necessitating endodontic treatment. Both the failures and the root resorptions occurred in patients bone grafted at an older age than was considered optimal for bilateral clefts: 10 to 11 years. Seven patients needed a bridge prosthesis, 3 of these over one cleft space only. Even these patients benefited greatly from bone grafting.     

Orthodontic-surgical interaction in the management of cleft lip and palate

The orthodontist's role in the cleft palate team requires close collaboration with the surgeons and other team members. The rationale of timing and sequencing of orthodontic treatment have been discussed in the various time frames, which for convenience have been considered as follows: (1) neonatal or infant maxillary orthopedics; (2) orthodontic considerations in the primary dentition; (3) mixed dentition orthodontics to include presurgical recommendations before an alveolar bone graft and its rationale for use in selected patients; and (4) orthognathic surgery combining an orthodontic and surgical approach to the correction of dental and skeletal components of malocclusion in the permanent dentition. Speech considerations and the communicative skills of the patient with a cleft are important aspects in planning orthognathic surgery for this group of patients. Also, subsequent nose and lip revisions for cosmetic improvement must not be underestimated in the enhancement of the final result following correction of the skeletal and dental discrepancies. Provided the timing and sequencing of appropriate treatment modalities are planned in a closely coordinated, problem-oriented approach by the team members, cleft patients should currently have optimal functional and esthetic results.     

单侧完全性唇腭裂患者自体骨移植修复牙槽突裂后早期牙移入的CT评价

目的 应用螺旋CT评价早期移动裂隙两侧的牙齿给予植骨区适当的功能刺激能否减少牙槽突裂植骨术后植入骨的吸收,增加新骨的形成,从而提高植骨手术成功率及植骨效果.方法 牙槽突裂患者12例,年龄9～13岁,分为两组：正畸牙移动组（A组）,在牙槽突裂植骨术后早期进行正畸牙移动;对照组（B组）只是行自体骨牙槽突裂植骨术.在植骨前后和正畸治疗后进行三维CT扫描,并对获得数据进行重建分析,观察正畸牙移入植骨区域后,正畸牙位置及牙槽骨的形态及体积变化.结果 两组在术前裂隙宽度及牙槽突裂体积均未见明显差异.术后6个月A组的新骨成骨体积为（0.98±0.23） mm3,显著大于B组的（0.73±0.15） mm3.新骨形成率在A组为（72.5±11.9）％,显著大于B组的（53.2±9.7）％.牙槽突裂患者自体骨植骨术后,早期正畸牙移动可顺利使裂隙侧牙齿移入植骨区域,正畸牙的牙根尖位置发生明显的位移,CT断面未见明显牙根吸收.结论 早期正畸牙移动可明显减少牙槽突裂植骨术后植入骨的吸收,其对植入骨的改建有明显的积极作用.     

Therapeutic approach of cleft lip and palate at Caen University Hospital

The therapeutic approach of facial cleft in Caen University Hospital depend on two teams: primary treatment by the Pediatric Plastic Unit (60 cases/year), and secondary treatment by the department of Plastic and Maxillofacial Surgery (more than 30 cases/year). The lip closure is realised before the age of one month with the Tennisson's technic. The palate closure is performed between 6 and 12 months old. Each patient is presented at a multidisciplinary consultation which include a surgeon, an orthodontist, an orthophonist, a psychologist and otologist. At about 5 years old, the orthodontic approach begins with palatal expansion with a modified quadhelix to prepare function its treatment is underwent at this age too. After the age of 9-10 years the orthodontic treatment continued on the permanent teeth. If necessary, the sequelae on maxilla, lips and nose are treated at the end of the adolescence.     

Multidisciplinary management of a patient with van der Woude syndrome: A case report

IntroductionVan der Woude syndrome (VWS) is the most frequent form of syndromic cleft lip and palate (SCLP) accounting for 2% of all patients with CLP.Case presentationWe describe the orthodontic treatment of a girl diagnosed with VWS referred by her family dentist for her cosmetic concerns.DiscussionComprehensive orthodontic treatment, secondary bone graft, distraction osteogenesis (for a deficient maxilla), secondary palatoplasty and excision of lower lip pits, as well as orthodontic and prosthetic procedures may provide a satisfactory outcome. Genetic testing showed a known putative splice site mutation (c.174 + 1 G/A) as the prime cause of VWS in our patient and her family.ConclusionSCLP has significant effects on facial aesthetics and the psychosocial status. Parents should be assessed and counseled appropriately. This condition is treatable in the absence of life threatening systemic anomalies. An interdisciplinary team approach is advocated.     

唇腭裂的牙槽突裂植骨修复术

牙槽突植骨术是唇腭裂序列治疗的一个组成部分，对于恢复上颌牙弓的完整性，保证上颌牙齿的正常萌出，促进上颌骨的垂直向生长及颌骨的稳定性，矫正患侧鼻底塌陷畸形及修复唇侧口鼻腔瘘均有重大意义。总结了保证手术成功的关键，并认为植骨术前后应接受正畸治疗。８～１１岁Ｘ线片示尖牙根形成２／３为最佳手术时间。     

唇腭裂的牙槽突裂植骨修复术

牙槽突植骨术是唇腭裂序列治疗的一个组成部分,对于恢复上颌牙弓的完整性,保证上颌牙齿的正常萌出,促进上颌骨的垂直向生长及颌骨的稳定性,矫正患侧鼻底塌陷畸形及修复唇侧口鼻腔瘘均有重大意义。总结了保证手术成功的关键,并认为植骨术前后应接受正畸治疗。8～11岁 X 线片示尖牙根形成2/3为最佳手术时间。     

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.     

Maxillofacial osteotomies for patients with cleft lip and palate

A variety of dental malocclusions may be found in the patient with cleft lip and palate. These range from trivial dental rotation to major dentoskeletal disharmonies. Some of these deformities are intrinsic to the cleft malformation whereas others are secondary deformations resultant from specific management options taken in childhood. In most cases, a combination of orthodontics and orthognathic surgery is necessary to correct the deformity, that is, normalize the dentition, the facial skeleton, and the facial appearance. The timing of intervention, dependent upon the specific problem, is chosen to minimize negative secondary effects. Stability of mobilized and repositioned maxillary segments remains a problem in spite of the use of rigid internal fixation miniplates. The role of bone grafting when miniplates are used is unclear. While it is clear that movement of the maxilla, segmentally or in toto, can correct major dentoskeletal deformities in cleft patients, much remains to be learned regarding the best means of executing such operations.     

齿槽裂修复方法的研究进展

目的探讨齿槽裂修复治疗的目的、方法以及治疗时机的选择。方法查阅1950年至2006年有关齿槽裂修复的文献,归纳文献中报道的不同方法,并评价其各自的优缺点。结果齿槽裂修复的主要目的:关闭口鼻瘘;建立稳定、连续的上颌骨牙弓;为牙齿萌出提供基础;为上唇和鼻底提供稳定支架。主要治疗方法:植骨术;牵引成骨技术;组织工程骨和生长因子应用;引导骨再生技术。患者最佳的手术治疗时机是9~11岁时混合牙列期。结论在9~11岁混合牙列期手术,以髂骨松质骨为移植材料被认为是修复齿槽裂的主要手段。牵引成骨技术、组织工程技术和引导骨再生技术,将是齿槽裂修复的新方向。     

Secondary Bone Grafting of Alveolar Clefts: A Surgical/Orthodontic Treatment Enabling a Non-prosthodontic Rehabilitation in Cleft Lip and Palate Patients

A procedure combining grafting of cancellous bone to the residual cleft of the primary palate with subsequent orthodontic movement of teeth into the former cleft area is described. The preliminary results from the first 80 patients (89 clefts) are presented. The age of the patients at the bone grafting ranged from 8 to 18 years, and the observation time from 17 to 44 months. The results have been assessed 1) on the basis of dental radiographs and 2) clinically, by the response of the grafted area to the orthodontic movement of adjacent teeth. In 69 clefts in which the cleft side canine had been brought into its final position at the time of evaluation, the height of the interal-veolar septum was assessed to be approximately normal in 38% and slightly less than normal in 44%. A septum of insufficient height (less than 3/4 of the normal) had formed in 5 clefts (7%). Even in these cases, the main objects of the operation were fulfilled: The maxillary segments were stabilized, the teeth adjacent to the cleft had better bone support, and the gap in the dental arch could be closed orthodontically in four of the five clefts. Failures, i.e. no continuous bone bridge across the alveolar cleft, were recorded in 8 instances (9%) of the total material. When failures were disregarded, the gap in the dental arch was closed orthodontically in 90%, while prosthodontic closure was deemed necessary in 10% of the cases. Optimal results were obtained when bone grafting was performed prior to the full eruption of the cleft side canine. In this situation, the known potential of an erupting tooth to induce alveolar bone generation proved to be of great advantage. By deliberately guiding the erupting canine through the grafted area close to the incisor, a nearly normal interalveolar septum was formed, and the gap in the dental arch was closed orthodontically in 23 out of 26 clefts. When fissural teeth were present, they were in most cases integrated in the dental arch. Approximate incisor symmetry could thus be obtained. In the remaining 20 clefts, the ipsilateral canine had not reached its final position at the time of evaluation, and the end results could not be assessed. However, bone formation in the defect was good in 19 of the 20 clefts, and a fully satisfactory result is expected in the majority of these cases. Further advantages were obtained by this procedure: 1) The maxillary segments were stabilized, particularly important in bilateral clefts in which the premaxilla was movable. 2) Oronasal fistulae were effectively closed and mucosal recesses eliminated. 3) The grafted bone provided support for the receded alar base, reducing the nasal asymmetry and improving the facial contour. 4) The postoperative orthodontic treatment could be brought to an end at approximately the same age as for patients with a non-cleft malocclusion. The only significant complication in this series was infection of the grafted area, causing loss of the bone grafts in two cases, and possibly contributing to the failure in some other patients. The experience gained with this treatment permits the conclusion that a full osseous and dental rehabilitation can be achieved in the great majority of patients with cleft lip and palate without any prosthodontic reconstructive work.     

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.     

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。     

Spontaneous tooth eruption after alveolar cleft osteoplasty using tissue-engineered bone: a case report.

To bridge the cleft in the alveolar bone and to allow for physiologic eruption of the canine teeth, alveolar bone grafting is often necessary in patients with cleft lips and palates. Instead of autogenous bone, biomaterial seeded with autogenous osteogenic cells has found some clinical application. However, so far no real functional proof has been available to demonstrate that this technique also allows further physiologic features such as tooth eruption to occur. This report describes the results of grafting tissue-engineered bone into the alveolar cleft of a 10-year-old boy. Immediate postoperative healing was uneventful. Eight months after grafting, erupting teeth had moved into the newly formed bone. Eighteen months postoperatively at the site where the tissue-engineered graft had been inserted, the canine had erupted spontaneously in its proper place. The data suggest that tissue-engineered bone can lead to the ossification of the alveolar cleft and allow for physiologic spontaneous tooth eruption.     

Dentofacial relations in young adults with unilateral complete cleft lip and palate. A follow-up study

A retrospective study was made on 30 patients born between 1958 and 1969 with unilateral complete cleft lip and palate (C-UCLP) and operated on at the Department of Plastic Surgery, University Hospital, Ume?, Sweden. All patients were operated on by the same surgeon. The results are based on data from records at 5, 10, 16 and 20 years of age. The facial morphology of the cleft children at 5 years of age was rather close to that of the normal children. During growth the faces became retrognathic, more visibly so in the maxilla resulting in straight or concave profiles. This was more evident among the boys. There were no differences regarding maxillary growth between children bone grafted at 10 to 16 years of age and those bone grafted after 16 years of age or not at all. Although surgical procedures and orthodontic treatment varied, 70% had less than 3 teeth in crossbite relationships at 20 years of age. An important factor to take into consideration is the fact that in addition to the influence that the cleft morphology and treatment have on the dentofacial growth, other dentofacial growth patterns also exist among the cleft patients. Generally the groups of patients reported are rather small and therefore conditions like these can have a strong influence on the results.     

Cleft lip,maxilla and palate treatment by Dr. Talmant's team in Nantes

Over the last 30 years, our private cleft lip and palate team has developed an increasing activity based on the Victor Veau's concept: "All the structures are present and only deformed". Our goal is to achieve an anatomical and fully functional repair in every fields with the first operation. A few recent refinements have improved our primary procedures: intravelar veloplasty; simultaneous lengthening of the columella and primary lip repair in bilateral clefts; nasal retainer for the 3 or 4 first postoperative months allowing the establishment of a nasal breathing mode at once. Our timing has been the same over the last 21 years if we except that we currently perform the gingivoperiosteoplasty between 4 and 5 years of age so that the width and the relationships of the maxillary arch are normal at the time of the mixed dentition. The timing is the same in uni and bilateral clefts. No preoperative orthopedics. At 6 months of age, nasolabial repair and closure of the soft palate with intravelar veloplasty. At 18 months of age, anatomical closure of the residual cleft of the bony palate in two planes without vomer flap or denuded bone. Between 4 and 5 years of age, after a short orthopedic treatment, closure of the alveolar cleft by a gingivoperiosteoplasty with iliac bone graft. From 6 years of age we start the orthodontic treatment. The current evolution allows to think that only few late corrections will be necessary.