Use of autologous platelet derivatives for secondary alveoloplasty in patients with cleft lip and palate: a systematic review and meta-analysis.

This study aimed to evaluate the effectiveness of autologous platelet derivatives (APD), specifically platelet-rich plasma (PRP) or platelet-rich fibrin (PRF), combined with autogenous iliac crest bone grafts in secondary alveoloplasty for patients with cleft lip and palate. Electronic databases, relevant journals, and reference lists of included studies were searched until July 2022. Best-evidence synthesis was performed to draw conclusions. After the search strategies, 12 randomized controlled trials were included that provided data on six outcomes: newly formed bone, mean bone loss in height and width, bone density, functionality, and postoperative complications. Two authors independently assessed the risk of bias, and the certainty of evidence was assessed using the GRADE approach. The pooled results suggest that there is uncertainty as to whether the combination of APDs with autogenous iliac crest bone grafts improves the percentage of newly formed bone, as the certainty of the evidence was assessed as very low. It may slightly improve the functionality of patients (with low certainty of the evidence) and probably slightly reduces the incidence of postoperative complications (with moderate certainty of evidence). Further randomized clinical trials with standardized methodologies are required to validate these findings.

Race-Based Differences in the Utilization and Timing of Secondary Cleft Procedures in the United States.

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.

Alveolar Distraction.

Alveolar distraction osteogenesis (ADO) has been used for the reconstruction of atrophic alveolus for decades. The advantage of this technique is that it augments the bone and soft tissues together, creating a better alveolar platform for subsequent surgeries and dental rehabilitation. It is especially useful in patients with large and/or complex alveolar clefts for which approximating the alveolar segments reduces the size of the bony cleft and associated fistula. Displacement of the transported segment is the most frequently encountered complication of ADO but can be managed by constructing case-specific distractors.

[Alveoloplasty and the use of osteosynthesis material in the cleft lip palate]. / Alveoloplastias y utilización de material de osteosíntesis en la fisura labiopalatina.

OBJECTIVES: To compare the results of secondary alveoloplasty performed in one Hospital when osteosynthesis material was used and when the bone graft does not require this material, and relating them to factors such as gender and age. MATERIAL AND METHODS: A retrospective study was conducted from the years 2014 to 2019 in this Hospital on the selected patients who met the inclusion criteria. Two periods of ages, period A: ages between 5-12 years (mixed secondary alveoloplasty) and period B: greater than 12 years (late secondary alveoloplasty). Autologous bone from the iliac crest or parietal calotte was used for the bone graft. The patients were divided into 2 groups: group I: patients with alveoloplasties that required osteosynthesis material. Group II: patients who did not require osteosynthesis material. Parameters evaluated: the success criteria for alveoloplasty were assessed according to the clinical parameters described by Precious. Alveoloplasty was successful if they met all the criteria of Precious in the year of intervention. Postoperative complications in both groups were evaluated. The statistical analysis was performed using the exact Fisher test for qualitative variables. RESULTS: Alveoloplasty was successful in 89.4% of patients in group I, while it was 90.3% in group II. Alveoloplasty was successful in 87.5% of females compared to 91.17% of males. The intervention was a success in 91.48% of patients in group A, compared to 66.6% in group B. The osteosynthesis material in two patients of group I was not degraded in the annual assessment. There were no significant differences in any of the comparisons. CONCLUSIONS: The use of osteosynthesis material does not alter the integration of the bone graft in patients that undergo alveoloplasty. Factors such as gender or age do not influence the results of the interventions.

Assessment of Bone Formation After Secondary Alveolar Bone Grafting With and Without Platelet-Rich Plasma Using Computer-Aided Engineering Techniques.

The aim of this study was to analyze the newly formed bone volume (FV), 6 months after secondary alveoloplasty using iliac cancellous bone graft, with and without platelet-rich plasma (PRP). Forty patients with unilateral alveolar cleft were involved in this randomized, prospective, comparative study, with 20 patients each forming the control (group A) and PRP (group B) groups, respectively. The preoperative alveolar defect volume (DV) and the postoperative FV were automatically calculated by the computer-aided engineering software using the patients' pre and postsurgical computed tomography data. The volume of the actual bone graft (AV) was identical to the DV calculated before surgery. The bone formation ratio (BF%) was calculated as follows: BF% = (FV/AV) × 100%. The mean BF% was 42.54 ±â€Š9.32% in group A and 46.97 ±â€Š18.49% in group B. There was no statistically significant difference between the 2 groups for BF% (P > 0.05). The study presents a fast and accurate method for assessing the effect of PRP in alveolar grafting. However, the study found no conclusive evidence on the effect of PRP on bone growth.

Application of Hydroxycholesterols for Alveolar Cleft Osteoplasty in a Rodent Model.

BACKGROUND: Bone morphogenetic proteins (BMPs) have played a central role in the regenerative therapies for bone reconstruction, including alveolar cleft and craniofacial surgery. However, the high cost and significant adverse effect of BMPs limit their broad application. Hydroxycholesterols, naturally occurring products of cholesterol oxidation, are a promising alternative to BMPs. The authors studied the osteogenic capability of hydroxycholesterols on human mesenchymal stem cells and the impact of hydroxycholesterols on a rodent alveolar cleft model. METHODS: Human mesenchymal stem cells were treated with control medium or osteogenic medium with or without hydroxycholesterols. Evaluation of cellular osteogenic activity was performed. A critical-size alveolar cleft was created and one of the following treatment options was assigned randomly to each defect: collagen sponge incorporated with hydroxycholesterols, BMP-2, or no treatment. Bone regeneration was assessed by means of radiologic and histologic analyses and local inflammation in the cleft evaluated. Moreover, the role of the hedgehog signaling pathway in hydroxycholesterol-mediated osteogenesis was examined. RESULTS: All cellular osteogenic activities were significantly increased on human mesenchymal stem cells treated with hydroxycholesterols relative to others. The alveolar cleft treated with collagen sponge with hydroxycholesterols and BMP-2 demonstrated robust bone regeneration. The hydroxycholesterol group revealed histologically complete bridging of the alveolar defect with architecturally mature new bone. The inflammatory responses were less in the hydroxycholesterol group compared with the BMP-2 group. Induction of hydroxycholesterol-mediated in vitro osteogenesis and in vivo bone regeneration were attenuated by hedgehog signaling inhibitor, implicating involvement of the hedgehog signaling pathway. CONCLUSION: Hydroxycholesterols may represent a viable alternative to BMP-2 in bone tissue engineering for alveolar cleft.

Importance of Stem Cell Transplantation in Cleft Lip and Palate Surgical Treatment Protocol.

Cleft lip and palate is a congenital malformation that requires a multidisciplinary treatment that evolves pediatrician, obstetrics, fetal medicine, genetics, plastic surgery, orthodontics, speech therapist, nursery, and psychology. Actually, the authors believe that it could be possible to ad protocols to use stem cells.The intrauterine diagnosis leads to preborn parental orientation and better parental collaboration to accept a precocious multidisciplinary treatment. After birth the authors' protocol is: orthodontic devices, phonoaudiology, and surgical procedures.The authors' cleft lip and palate reconstructive surgery protocol demands several steps and begins at 4 to 6-month old with rhinocheiloplasty and soft palate closure at the same moment. The treatment sequence involves the hard palate surgery (8-18 months after the first surgical step), alveoloplasty (after 10 years old), and secondary rhinoplasty (after 14 years old).New ideas to use stem cells and blood from the umbilical cord and also blood from placenta are discussed to improve final surgical results. Maternal stem cells are easy to collect, there are no damage to the patient and mother, it is autologous and it could be very useful in the authors' protocol.Nine patients with clef lip and palate were operated and had stem cells from umbilical cord blood and placenta blood injected into the bone and soft tissue during the primary procedure (rhinocheiloplasty).The stem cells activity into soft tissue and bone were evaluated. Preliminary results have shown no adverse results and improvement at the inflammatory response. A treatment protocol with stem cells was developed. It had a long time follow-up of 10 years.

Crown lengthening and restorative procedures in the esthetic zone.

Crown lengthening is one of the most common surgical procedures in periodontal practice. Its indications include subgingival caries, crown or root fractures, altered passive eruption, cervical root resorption and short clinical abutment, and its aim is to re-establish the biologic width in a more apical position. While the procedure in posterior areas of the dentition has been thoroughly investigated, crown lengthening performed for esthetic reasons in the anterior areas is still a matter of debate and an evidence-based technique is not available. This paper provides accurate descriptions of the surgical and restorative phases of the esthetic crown-lengthening procedure by answering the following questions: what is the ideal surgical flap design? how much supporting bone should be removed? how should the position of the flap margin relate to the alveolar bone at surgical closure? and how should the healing phase be managed in relation to the timing and the position of the provisional restoration with respect to the gingival margin?

Outcomes of 44 Consecutive Complete Bilateral Cleft Lip and Palate Patients Treated With Secondary Alveolar Bone Grafting and Premaxillary Osteotomy.

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

Computed Tomographic Estimation of Particulate Cancellous Bone and Marrow Weight for Successful Transplant in Unilateral Cleft Lip and Palate Patients.

OBJECTIVE: The defect volume measured on computed tomography (CT) for secondary bone graft (SBG) is well correlated to the actual amount of particulate cancellous bone and marrow (PCBM) transplanted in unilateral cleft lip and palate (UCLP) patients. However, the validity of such measurements have not been completely verified due to lack of evaluation of treatment results. The objective of this study was to propose an estimation method by CT based on the data of successfully treated patients. For this purpose, the association was initially verified between the weight of transplanted PCBM and the defect volume measured on CT using the results of successfully treated patients. METHODS: Treatment results were evaluated 1 year after SBG by intraoral radiography in 50 UCLP patients. For the patients with good results, the correlation was investigated between the defect volume on CT and the transplanted PCBM weight, and a method was proposed based on PCBM density, calculated as PCBM weight divided by defect volume on CT. RESULTS: In successfully treated patients showing level 3 or 4 alveolar resorption, a strong correlation (r = .87) was found between the volume on CT and the PCBM weight. Level 4 results were observed in 22 of 23 (95.7%) patients who had calculated PCBM densities of more than 6 g/cm3. CONCLUSIONS: Volume estimation on preoperative CT was confirmed to have sufficient validity. The weight of PCBM transplanted should be greater than the defect volume on CT multiplied by 6.

Long-term outcomes of simplified gingivoperiosteoplasty performed at the time of hard palatal closure: A review of 55 alveolar clefts.

Few studies have examined the long-term outcomes of gingivoperiosteoplasty at the age of permanent canine eruption. The success rates of gingivoperiosteoplasty vary significantly depending on the surgeon because of the difficulty of the surgical technique. Therefore, the authors utilized a simplified gingivoperiosteoplasty technique by inserting one or two large, triangular-shaped mucoperiosteal flaps on the opposite side in a tongue-in-groove or interdigitation fashion. The purpose of this study was to evaluate the long-term outcomes of this simplified gingivoperiosteoplasty technique at the age of permanent canine eruption. Forty nonsyndromic cleft lip and palate patients who had undergone simplified gingivoperiosteoplasty were retrospectively reviewed. Canine eruption and the bone formation rate of the interalveolar septum using the Bergland method and a modified Long et al. method were evaluated. A total of 55 alveolar cleft sites were treated. Simplified gingivoperiosteoplasty was performed at a mean age of 13.4 months, and the mean age at the time of follow-up was 14.3 years. The overall success rate of simplified gingivoperiosteoplasty was 50.90%. With regard to cleft types, clefts of the primary palate and unilateral alveolar clefts showed a significantly higher success rate than clefts of the primary and secondary palates and bilateral alveolar clefts, respectively. Our gingivoperiosteoplasty technique is a simple surgical procedure and is performed at 12 months of age, at which time the cleft alveolus has grown sufficiently, to ensure the success of the delicate surgical technique. Therefore, we could obtain favorable outcomes.

Alveolar bone grafting with simultaneous cleft lip rhinoplasty.

BACKGROUND: Optimal timing for cleft lip rhinoplasty is controversial. Definitive rhinoplasty is deferred until facial skeletal growth is completed. Intermediate rhinoplasty is performed after stabilization of the grafted alveolar bone, because the grafted bone tends to be absorbed over several months postoperatively, distorting the nasal profile. Here, we report our experience with simultaneous rhinoplasty during alveolar bone grafting for indicated patients, describe our surgical technique that ensures long-term bone graft survival, and report graft take rates and nasal profile changes. METHODS: This retrospective chart review included a total of 54 patients; 44 underwent alveolar bone grafting only, and 10 underwent simultaneous cleft lip rhinoplasty. All surgeries were conducted with a judicious mucosal incision for tensionless wound closure. Bone graft take was evaluated with dental radiographs by the Bergland classification. Further, nasal aesthetic outcome was evaluated with medical photographs, based on nostril height and width and alar base width. RESULTS: In total, 96.3% of clefts showed graft success with Type I (66.7%) or Type II (27.8%) classifications; only 3.7% of clefts showed unfavorable results classified as Type III, and no clefts showed Type IV failure. The nasal shape was flatter with a decreased nostril height and increased nostril width after alveolar bone grafting, while nostril height was increased and nostril width was decreased in patients who underwent simultaneous rhinoplasty. CONCLUSION: With surgical techniques ensuring alveolar bone graft survival, simultaneous cleft lip rhinoplasty can result in nasal aesthetic improvement for patients with severe nasal deformities, decreasing the number of operations.

Autologous bone grafting with platelet-rich plasma for alveolar cleft repair in patient with cleft and palate.

PURPOSE: Bone grafting of the alveolus has become an essential part of the contemporary surgical management of the oral cleft. The aim of this retrospective study was to evaluate the results of bone grafting in association with PRP (plateletrich plasma) to enhance osteogenesis and osteointegration. PATIENTS AND METHODS: The study included 16 patients, aged between 9 and 11, affected with unilateral residual alveolar clefts, who underwent bone grafting using secondary alveoplasty. The eight patients belonging to the control group were administered autologous bone graft alone while the study group, consisting of 8 patients, underwent autologous bone grafting in association with PRP. All patients had pre and post surgery orthodontic treatment. The statistical analyses included Student's t test, 2 test and Kaplan-Meir time to event analysis. The p-value was considered significant if p<0.05. All statistical analyses were performed using SAS Software release 9.3 (SAS Institute, Cary, Nc). RESULTS: The control group (M 50%, mean age 10.2±2.3) underwent simple autologous bone graft while the study group (M 62.5%, mean age 9.9±2.2) was treated with a combination of autologous bone and PRP. No statistically significant differences were found between the two groups as regards age, gender and labial-palatal cleft clinical characteristics. 6, 12, 24 month follow-ups were performed by means of clinical and radiographic investigations. None of the study group developed oronasal fistulas or experienced bone height, bone bridging and bone quality loss; only two patients developed mild periodontal problems. The study group was able to undergo a significantly (p<0.001) earlier and shorter orthodontic treatment. CONCLUSIONS: In our experience, the use of PRP enhances the quality of osteoplasty, accelerates "creeping substitution" and bone healing and favours earlier orthodontic treatment. KEY WORDS: Alveolar cleft, Bone grafting, Palate, Platelet-rich plasma.

"Tent-Pole" for Reconstruction of Large Alveolar Defects: A Case Report.

Severe tridimensional alveolar ridge defects complicate the placement of dental implants, and surgical removal of some oral tumors might not leave adequate bone for dental implant placement. Regenerating an adequate amount of bone vertically and horizontally to achieve a satisfying outcome for well-osseointegrated implants and thus ensure long-term success of implant restoration is challenging. This report describes the clinical feasibility of a simple approach using a screw tent-pole combined with guided bone regeneration to augment complicated tridimensional alveolar ridge defects in a case of extensive bone loss due to maxillary tumor surgery. Titanium screws were arranged in "tented" fashion to provide stable room for bone regeneration. Regenerated bone was achieved and 2 more implants were placed in the regenerated ridge 10 months later, leading to a successful maxillary prosthesis.

Full Mouth Implant-supported Rehabilitation of a Patient with Ectodermal Dysplasia: Clinical Report and Literature Review.

OBJECTIVE: The purpose of this case report is to present the clinical course of full mouth rehabilitation in an 1 8-year-old female patient with ectodermal dysplasia who was treated with implant-supported fixed partial dentures for the mandible and the maxilla. CASE REPORT: Fourteen dental implants (8 in the maxilla and 6 in the mandible) were placed simultaneously after full mouth extraction and alveoloplasty surgery. After 6 months of healing, prosthetic rehabilitation was started for screw-retained fixed partial dentures. The patient was followed for one year and a peri-implant maintenance regime established for six-month recalls. The patient was satisfied with the prosthesis both esthetically and functionally. Furthermore, the patient reported significant improvements in oral function and psychosocial activities. CONCLUSION: The use of dental implants to support full mouth prosthetic rehabilitation for adolescents with ectodermal dysplasia may provide a considerable improvement in function and esthetic compared to conventional removable prosthetic options. This has the potential to enhance the quality of life for these patients.

Calvarial Bone Grafting for Three-Dimensional Reconstruction of Severe Maxillary Defects: A Case Series.

PURPOSE: To evaluate the efficacy, associated morbidity, and results of a three-dimensional reconstruction technique for repairing severe defects of the maxilla using a calvarial autogenous bone graft and a soft tissue double-layered surgical approach in preparation for placing dental implants. MATERIALS AND METHODS: Bone defects of the maxilla consecutively reconstructed with calvarial autologous graft in the authors' institution were retrospectively evaluated. Patients with combined maxilla alveolar ridge defects with a width less than 4 mm and a height less than 7 mm (to the level of the maxillary sinus or the nostril), with at least three teeth involved, were included in the study. Calvarial bone blocks were sagittally sectioned in fine layers and fixed three-dimensionally in a boxlike structure with particulate bone inside. The purpose was to obtain an adequate amount of vertical and horizontal alveolar bone to enable restoration with dental implants at least 3.4 mm in diameter and 11 mm in length. RESULTS: Eleven reconstructive procedures were performed in 10 patients. Bone graft integration was successful in all of them. No major complications were observed in the donor cranial site. A mean bone gain of 5.04 mm (range, 3.4 to 7.8 mm) in height was obtained (standard deviation [SD], 1.69). The implant surgery was performed between the 15th and 19th weeks. A total of 28 implants were placed, and the mean follow-up time was 45 months (range, 23 to 65 months; SD, 12). The mean graft vertical resorption was 0.78 mm (range, 0.50-1.50 mm; SD, 0.00) 41 months after implant fixation. CONCLUSION: Three-dimensional reconstruction technique using calvarial bone grafts to restore severe segmental or crestal bone defects in the maxilla is an effective and predictable procedure that can increase the horizontal and vertical bone volume in preparation for the successful placement of dental implants.