Effectiveness of pre-alveolar bone graft orthodontics for patients with non-syndromic complete unilateral cleft lip, alveolus and palate: A systematic review and meta-analysis.

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.

Three-dimensional evaluation of secondary alveolar bone grafting in patients with unilateral cleft lip and palate: A 2-3 year post-operative follow-up.

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.

What is the Success Rate of Repeat Alveolar Bone Graft?

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.

Influence of Preoperative Inflammatory Status on Outcomes of Alveolar Bone Grafting in Patients With Cleft Lip.

After secondary alveolar bone grafting, the outcome of bone formation is always a problem that leads to repeat surgery. Bone formation is closely related to the inflammatory and immune status of patients. To achieve better bone formation results, this study aimed to investigate the influence of preoperative inflammatory indicators on the bone survival ratio (BSR) of secondary alveolar bone grafting. A retrospective study was conducted on 62 patients who underwent surgery by the same surgeon between January 2016 to December 2022. Demographic and laboratory data were included as independent variables. The BSR calculated from computed tomography data was included as the dependent variable. Pearson correlation analysis, Spearman correlation analysis, and multiple linear regression analysis were performed. The analysis results revealed significant correlations between BSR and preoperative inflammatory markers, including neutrophil percentage, neutrophil-to-lymphocyte ratio, lymphocyte percentage (L%), lymphocyte count, and monocyte-to-lymphocyte ratio. Multiple linear regression identified L% as an independent factor of BSR, with lower L% associated with higher BSR. Preoperative inflammatory markers may influence BSR after alveolar bone grating. A lower value of L% indicates a better postoperative bone formation outcome. Understanding these associations can aid clinicians in treatment planning and patient stratification.

Dental Rehabilitation of the Unilateral Cleft Dental Gap: A Single Institution Experience With Long-Term Follow-Up.

OBJECTIVE: The purpose of this study was to identify factors associated with the management of the cleft dental gap after alveolar bone grafting. METHODS: This was a retrospective cohort study of patients with unilateral cleft lip and alveolus or palate who had successful alveolar bone grafting. Our primary study outcome was alveolar cleft management (orthodontic closure or space maintenance). Our secondary study outcome was the rate of fixed dental rehabilitation. Univariate comparisons were made with SAS 9.4. RESULTS: The final study sample consisted of 54 patients. Most patients were treated with orthodontic closure (55.6%). Patients missing multiple teeth ( P < 0.01) were less likely to receive orthodontic closure. Orthodontic closure was not associated with differences in intermaxillary midline coincidence ( P = 0.22) or the need for LeFort advancement ( P = 0.15). Only 41.7% of patients who were managed with space maintenance obtained a fixed prosthesis. Hispanic ethnicity ( P < 0.01) and Medicaid insurance ( P < 0.01) were associated with lower rates of fixed dental rehabilitation. CONCLUSIONS: Orthodontic closure was the most common approach, and it did not result in significant maxillary midline distortion. Less than half of patients treated with space maintenance obtained fixed restorations. Socioeconomic barriers are likely preventing access to definitive dental rehabilitation in patients with unilateral cleft lip and alveolus or palate.

Comparison of Alveolar Bone Grafting Outcomes using CBCT in Individuals with UCLP Based on the Presurgical Orthodontic Treatment Methods.

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.

Validation and comparison of 2D grading scales and 3D volumetric measurements for outcome assessment of bone-grafted alveolar clefts in children.

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.

Factors Contributing to Canine Impaction in Patients With Unilateral Cleft Lip and Palate Undergoing Alveolar Bone Grafts.

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, χ2 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.

Autogenous dentin combined with mesenchymal stromal cells as an alternative alveolar bone graft: an in vivo study.

OBJECTIVE: Considering the chemical and structural properties of dentin, this study was aimed at evaluating the effect of dentin matrix alone or combined with mesenchymal stromal cells (MSC) on postextraction alveolar bone regeneration. MATERIAL AND METHODS: Wistar rats were subjected to tooth extraction with osteotomy and allocated into groups according to the graft inserted: (1) Gelita-Spon®, (2) Bio-Oss®, (3) Dentin, (4) MSC, (5) Dentin/MSC, and (6) Control. Maxillae were analyzed by means of hematoxylin and eosin (H&E) staining, immunohistochemical (IHC) analysis, microcomputed tomography (micro-CT), and scanning electron microscopy (SEM). Serum levels of calcium and phosphorus were quantified. RESULTS: The Bio-Oss group showed less bone than Gelita-Spon and Dentin/MSC; no other significant differences were seen in H&E analysis. The Bio-Oss group showed higher expression of collagen type I compared to the Dentin and Dentin/MSC groups and also higher osteocalcin expression than the Dentin/MSC group. There was a tendency of higher expression of osteopontin in the MSC, Dentin, and Dentin/MSC groups and higher VEGF in the MSC group. On micro-CT analysis, the Bio-Oss and the Dentin/MSC groups exhibited greater bone volume than the Control. Serum calcium and phosphorus levels did not significantly differ between the groups. SEM analysis depicted particles of Bio-Oss and dentin in the respective groups, as well as significant cellularity in the MSC group. CONCLUSION: Autogenous nondemineralized dentin is an alternative for alveolar bone grafting, which can be improved by combination with MSC. CLINICAL RELEVANCE: This work provides support for the clinical applicability of dentin graft alone or combined with MSC.

Alveolar cleft reconstruction using bone marrow aspirate concentrate and iliac cancellous bone: A 12-month randomized clinical study.

OBJECTIVE: This study aimed to compare the bone density and volume in patients with alveolar cleft reconstructions utilizing bone marrow aspirate concentrate with iliac graft versus iliac graft alone. MATERIAL AND METHODS: Thirty-six patients with unilateral alveolar cleft were randomly allocated into either an intervention group receiving an iliac bone graft mixed with bone marrow concentrate or a control group receiving an iliac bone graft. Cone beam CT was obtained preoperative, 6 and 12 months postoperatively to assess the bone density of the graft and bone volume of the alveolar defect, and then, the bone loss ratio was calculated. RESULTS: Bone volume and bone density demonstrated a statistically significant increase in the intervention group at 6 and 12 months. In contrast, the bone loss ratio decreased significantly in the intervention group throughout the follow-up period. CONCLUSION: A combination of bone marrow concentrate and iliac cancellous bone in alveolar cleft reconstruction may improve bone densities and volume in addition to decreasing graft loss rate. CLINICAL SIGNIFICANCE: Using of bone marrow aspirate concentrate will decrease the amount of the graft needed and decrease the ratio of bone loss at the grafted site by the time. Trial registration ClinicalTrials.org ( NCT04414423 ) 4/6/2020.

Secondary alveolar cleft grafting using autogenous mineralized plasmatic matrix (MPM) versus cancellous bone particles derived from anterior iliac crest.

OBJECTIVE: The essential concern of alveolar cleft grafting in patients of cleft lip and palate at the mixed dentition phase is to gain bone within the cleft area that provides closure of the oronasal communication with continuous and stable maxilla for future cleft teeth eruption or implantation. This study aimed to compare the effectiveness of mineralized plasmatic matrix (MPM) versus cancellous bone particles harvested from anterior iliac crest in secondary alveolar cleft grafting. PATIENTS AND METHODS: This prospective randomized controlled trial was conducted on ten patients with unilateral complete alveolar cleft requiring cleft reconstruction. Patients were randomly divided into two equal groups; group (1) included 5 patients who received particulate cancellous bone derived from anterior iliac crest (control group) and group (2) included 5 patients who received MPM graft prepared from cancellous bone derived from anterior iliac crest (study group). All patients received CBCT preoperatively, immediately postoperatively and after 6 months. On the CBCT, graft's volume, labio-palatal width, and height were measured and compared. RESULTS: The outcome of the studied patients 6 months postoperatively showed that the control group had significant decrease in the graft volume, labio-palatal width, and height compared to the study group. CONCLUSION: MPM allowed for the integration of bone graft particles inside a fibrin network, which offers positional stability of the bone particles, thus preserving their shape with subsequent "in situ" immobilization of the graft components. This conclusion was reflected positively in terms of maintained graft volume, width, and height compared to that of the control group. CLINICAL RELEVANCE: MPM allowed for maintenance of grafted ridge volume, width, and height.

Clinical Application of Allograft Bone of Alveolar Cleft Repair.

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.

Three-dimensional Assessment of Autologous Calvarial Bone Grafting for Alveolar Clefts Reconstruction in Pediatric Population: A Retrospective Study.

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.

A Comparative Evaluation of Iliac Crest Cortical-Cancellous Bone Blocks Graft With and Without Concentrated Growth Factors (CGFs) in Secondary Alveolar Bone Grafting: A Retrospective Study.

BACKGROUND: The purpose of this study was to investigate the clinical effect and bone resorption of iliac crest cortical-cancellous bone block grafts combined with concentrated growth factor (CGF) compared with iliac crest cortical-cancellous bone block grafts only in secondary alveolar bone grafting. MATERIALS AND METHODS: Eighty-six patients (43 in the CGF group and 43 in the non-CGF group) with unilateral alveolar clefts were examined. Patients (17 in the CGF group and 17 in the non-CGF group) were randomly chosen for radiologic evaluation. Quantitative evaluation of the bone resorption rate was made with cone-beam computed tomography and Mimics 19.0 software at 1 week and 12 months after surgery. RESULTS: The success rate of bone grafting was 95.3% and 79.1% in the CGF and non-CGF groups, respectively ( P =0.025). The mean bone resorption rate at 12 months postoperatively was 35.66±15.80% and 41.39±19.57% in the CGF and non-CGF groups, respectively ( P =0.355). The bone resorption patterns of the 2 groups were similar on the labial, alveolar process, and palatal sides, and there was no obvious bone resorption on the labial side in either group. Nasal side bone resorption in the CGF group was significantly less than that in the non-CGF group ( P =0.047). CONCLUSIONS: Cortical-cancellous bone block grafts reduce labial bone resorption, while CGF reduces nasal bone resorption and improves the success rate. The combination of bone block and CGF in secondary alveolar bone grafting is worthy of further clinical application.

Volumetric Analysis of Unilateral Alveolar Bone Defect Using Modified Subtraction in Older Chinese Patients.

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.

Cleft Size and Success of Secondary Alveolar Bone Grafting-A Systematic Review.

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 mm2, and mean volume 0.89 ± 0.33 cm3. 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.

A Survey of Bone Grafting Practice Patterns in North American Cleft Surgeons.

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.

Racial Disparities in the Timing of Alveolar Bone Grafting.

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.

Differences in Practice in Alveolar Bone Grafting Among American Cleft Palate-Craniofacial Association Members.

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.

3-Dimensional Craniofacial Imaging: A Template for Systematic Radiologic Evaluation for Alveolar Cleft Assessment and Planning.

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.