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.

Remoção de pré-maxila em paciente com fissura labiopalatina: relato de caso / Removal of the premaxilla in patient with cleft lip and palate: case report

Diversas anomalias craniofaciais acometem os seres humanos, dentre estas podem ser citadas as fissuras labiopalatinas. Ocorrem devido à mal formações congênitas e comprometem o desenvolvimento orofacial e maxilo-mandibular, gerando complicações estéticas e funcionais. O momento para abordagem cirúrgica em pacientes com deformidade deste tipo é crucial para atingir o melhor resultado. Entretanto, muitos deles não procuram atendimento ou não tem acesso aos centros especializados. A pré-maxila em portadores de fissura labiopalatina transforame bilateral, não submetidos a tratamento cirúrgico na infância, é comumente protruída, impedindo o desenvolvimento e função adequada da musculatura perioral/ Ainda, pode causar dificuldades alimentares,de fonação e, principalmente, estético. O objetivo do presente trabalho é relatar o caso de uma paciente acompanhada no serviço de cirurgia bucomaxilofacial OSID/UFBA, portadora de fissura labiopalatina, submetida à remoção de pré-maxila em idade adulta. O fechamento da fenda palatina não foi possível devido a idade da paciente e o grau de desenvolvimento do palato, tendo indicado tratamento com uso de prótese obturadora. Considera-se que quanto mais precoce e associado a uma boa técnica cirúrgica forem realizadas as intervenções primárias, menores serão as sequelas. Consequentemente, os resultados estéticos e funcionais serão mais prováveis, sendo desnecessária a remoção cirúrgica da pre-maxila(AU)

Several craniofacial anomalies affect humans and, among these, it can be cited the cleft lip and palate. These occur due to congenital malformations and compromise the orofacial and maxillo-mandibular development, causing aesthetic and functional complications. The moment of the surgical approach in patients with this type of deformities is crucial to achieve the best outcome, however, many of them do not seek care or have no access to specialized centers. The premaxilla in carries of bilateral cleft lip and palate when they are not submitted to a surgical treatment in childhood, is commonly protruding, impeding the development and function of the perioral musculature, besides difficult feeding, phonation and mainly aesthetic. The aim of this article is to report the case of a patient accompained with the Bucomaxillofacial Surgery Service from OSID / UFBA, with cleft lip and palate, submitted to pre-maxilla removal, in adulthood. The cleft palate closure was not possible due to the age of the patient and degree of development of the palate, indicating treatment with obturator prosthesis. It is considered that, the sooner and associated with a good surgical technique, primary interventions are performed, the fewer the sequelae and consequently the aesthetic and functional results, where, in most cases, surgical removal of the premaxilla will be unnecessary(AU)

The versatile "lip switch" or transitional flap vestibuloplasty combined with alveoloplasty and implant placement to treat atrophic mandibles with inadequate vestibules and attached tissue: A case series and review of the literature.

INTRODUCTION/AIMS: The edentulous mandibular ridge and associated shallow vestibule are often seen as a challenge in the oral rehabilitation of patients. Dental implants can provide an improvement in mastication and patient satisfaction. The aim of this study is to utilize a preprosthetic mucosal flap combined with a repositional periosteal flap concomitant with an alveoloplasty and placement of endosteal implants as a single-stage procedure in the anterior mandible. This approach provides a valued alternative for dental rehabilitation in patients with poor masticatory efficiency using a conventional denture. METHODS: Eight patients underwent the preprosthetic surgical plan in the oral surgery clinic of the dental school during a 1-year period. Age, sex, preoperative, and postoperative vestibular depth, as well as hard and soft tissue elements were measured (P < .05) at 4-6 months. RESULTS: Mean age was 53 years ± 14.62 (N = 8). Anterior mandible height was 19 ± 4.8 mm. A significant difference was measured using a two-tailed Student's t-test between pre- and postoperative vestibular depths, respectively (3.9 mm vs 10.5 ± 0.96 mm; P < .01). CONCLUSIONS: A lip switch vestibuloplasty combined with placement of two implants provide a one-stage procedure that is convenient, provides a shorter postoperative period, and can be financially affordable. Future research requires larger sampling to support this treatment as a standard of care.

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

OBJETIVOS: Comparar los resultados de alveoloplastias secundarias realizadas en nuestro Hospital cuando utilizamos material de osteosíntesis y cuando el injerto óseo no precisa de dicho material, relacionándolos con factores como el sexo y la edad. MATERIAL Y MÉTODOS: Realizamos estudio retrospectivo de los años 2014-2019 en nuestro Hospital y seleccionamos los pacientes que cumplían los criterios de inclusión en nuestro estudio. Establecimos 2 grupos de edades: grupo A, edades entre 5-12 años (alveoloplastia secundaria mixta); grupo B, más de 12 años (alveoloplastia secundaria tardía). Para el injerto óseo se utilizó hueso autólogo procedente de cresta ilíaca o calota parietal. Dividimos los pacientes en 2 grupos: grupo I, pacientes con alveoloplastias que precisaron de material de osteosíntesis; grupo II, pacientes que no precisaron de material de osteosíntesis. Parámetros evaluados: los criterios de éxito de la alveoloplastia se valoraron según los parámetros clínicos descritos por Precious. La alveoloplastia era exitosa si cumplían todos los criterios de Precious al año de intervención. Evaluamos las complicaciones postoperatorias en ambos grupos. El análisis estadístico se realizó con el test exacto de Fisher para variables cualitativas. RESULTADOS: El éxito de la alveoloplastia se produjo en el 89,4% de los pacientes del grupo I, mientras que en el grupo II fue del 90,3%. La alveoloplastia fue exitosa en el 87,5% del sexo femenino frente al 91,17% de varones. En el 91,48% de los pacientes del grupo A la intervención fue un éxito frente al 66,6% del grupo B. En 2 pacientes del grupo I el material de osteosíntesis no se degradó en la valoración anual. No existieron diferencias significativas en ninguna de las comparaciones. CONCLUSIONES: La utilización de material de osteosíntesis no altera la integración del injerto óseo en pacientes a los que se realiza alveoloplastia. Factores como el sexo o la edad no influyen tampoco en los resultados de las intervenciones

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

Aplicación de la tecnología CAD/CAM para el manejo de la fisura alveolar: a propósito de un caso clínico / Application of CAD/CAM technology for alveolar cleft management: a case report

El paciente fisurado requiere un abordaje multidisciplinar e individualizado, siendo imprescindible adaptar la secuencia de tratamiento a cada paciente, según su situación clínica, sus necesidades y sus expectativas. Uno de los problemas más frecuentes del paciente fisurado es, entre otros, el colapso transversal del maxilar. La tecnología CAD/CAM nos permite la planificación virtual e impresión 3D, facilitando el abordaje y tratamiento integral del paciente fisurado en la actualidad. El propósito de este artículo es mostrar el manejo de la fisura alveolar de un paciente adulto con fístula oronasal y maloclusión dental por colapso transversal del maxilar, en el cual se aplica la tecnología CAD/CAM para optimizar los tiempos quirúrgicos y de rehabilitación dental protésica. Discutir acerca de las posibilidades terapéuticas y los beneficios de la implementación de los avances en técnicas CAD/CAM

Cleft patient requires a multidisciplinary and individualized approach, being essential to adapt the treatment sequence to each patient, according to their clinical situation, their needs and their expectations. One of the most frequent problems of the cleft patient is, among others, the transverse collapse of the maxilla. CAD/CAM technology allows virtual planning and 3D printing that facilitates the comprehensive approach and treatment of the cleft patient today. The purpose of this article is to show the management of the alveolar cleft of an adult patient with oronasal fistula and dental malocclusion due to transverse maxillary collapse, in which CAD/CAM technology is applied to optimize surgical and prosthetic dental rehabilitation times. Discuss the therapeutic possibilities and benefits of implementing advances in CAD/CAM techniques

[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.

Análise das exodontias realizadas na atenção primária da Região Metropolitana de Belo Horizonte / Analysis of tooth extractions performed in the primary health care of the Belo Horizonte metropolitan region

Objetivo: Analisar as exodontias de dentes permanentes (exodontia de dente permanente e múltipla com alveoloplastia por sextante) realizadas na atenção primária da Região Metropolitana de Belo Horizonte (RMBH). Métodos:Para a coleta de dados, foi utilizado o banco de dados da produtividade da atenção primária, da RMBH, ano de 2017, disponibilizado pelo Departamento de Informática do Sistema Único de Saúde (SUS). A variável dependente foi o indicador nº 21 do SUS, que corresponde ao percentual de exodontias realizadas dentre os procedimentos da atenção primária, cujo parâmetro deve ser ≤ 8% (≤ 8% e > 8%). As variáveis independentes foram: dados sociodemográficos (localização, população, Índice de Desenvolvimento Humano ­ IDH e Índice de Gini) e de saúde (cobertura de Estratégia de Saúde da Família ­ ESF e Equipes de Saúde Bucal ­ ESB e presença de Centro de Especialidades Odontológicas ­ CEO). Associações foram avaliadas por meio dos testes do Qui-Quadrado de Pearson e Exato de Fisher (p < 0,05), utilizando o programa SPSS 22.0. Resultados:Foram analisados 49 municípios, sendo 67,3% do núcleo metropolitano. A mediana populacional foi de 25.537 habitantes, com IDH médio de 0,707 e Índice de Gini mediano de 0,464. As medianas de cobertura da ESF e ESB foram, respectivamente, 96,7% e 52,7%. Apenas 32,7% dos municípios apresentaram CEO. O indicador nº 21 do SUS apresentou uma mediana de 6,7%. Não houve associação entre o indicador nº 21 do SUS e as variáveis sociodemográficas e de saúde (p > 0,05). Conclusão:A RMBH apresentou valores satisfatórios em relação ao percentual de exodontias realizadas, provavelmente devido aos bons indicadores socioeconômicos e de saúde bucal apresentados.

Aim: To analyze the extractions of permanent teeth (extraction of permanent teeth and extraction of multiple teeth with alveoloplasty per sextant), performed in a primary health care unit of the Metropolitan Region of Belo Horizonte (MRBH). Methods:For data collection, the primary care productivity database of 2017 from MRBH, provided by the Department of Information Technology of the Brazilian Unified Health System (SUS in Portuguese), was used. The dependent variable was the SUS indicator number 21, which corresponds to the percentage of extractions performed among primary dental care procedures, whose parameter must be ≤ 8% ( ≤ 8% and > 8%). The independent variables were: sociodemographic data (location, population, Human Development Index (HDI), and Gini Index) and health (coverage of Family Health Strategy (FHS) and Oral Health Teams (OHT), as well as the presence of Dental Specialty Centers (DCS). Associations were evaluated using the Pearson's Chi-square and Fisher's Exact tests (p < 0.05), using the SPSS 22.0 program. Results: This study analyzed 49 municipalities, 67.3% of which were metropolitan areas. The median population was 25,537 inhabitants, with a mean HDI of 0.707 and a median Gini index of 0.464. The median coverage of ESF and ESB were 96.7% and 52.7%, respectively. Only 32.7% of the municipalities presented CEO. The SUS indicator number 21 presented a median of 6.7%. No association was found between the SUS indicator number 21 and the sociodemographic and health variables (p > 0.05). Conclusion: The MRBH presented satisfactory values in relation to the percentage of tooth extractions, most likely due to the good socioeconomic and oral health indicators presented.

Comparing intra-oral wound healing after alveoloplasty using silk sutures and n-butyl-2-cyanoacrylate

OBJECTIVES: The need for proper wound closure is of paramount importance after any intra-oral surgery. Various wound closure techniques have been described in literature using traditional non-absorbable suture materials. These include like synthetic absorbable sutures, surgical staples and tissue adhesives. Cyanoacrylates are among the most commonly used biocompatible tissue adhesives. To evaluate and compare intraoral wound healing using 3-0 silk sutures and n-butyl-2-cyanoacrylate after alveoloplasty.MATERIALS AND METHODS: A total of 20 patients requiring bilateral alveoloplasty in the same arch (upper or lower) were included in this study. Patients with any pre-existing pathology or systemic disease were excluded. After alveoloplasty was performed, the wound was closed using 3-0 braided silk sutures on one side, and using n-butyl-2-cyanoacrylate bio adhesive on the other side. Patients were evaluated based on the following parameters: time required to achieve wound closure; the incidence of immediate and postoperative hemostasis; the time to the use of the first rescue medication; the side where pain first arises; and the side where wound healing begins first.RESULTS: Compared to 3-0 silk sutures, cyanoacrylate demonstrated better hemostatic properties, reduced operative time, reduced postoperative pain and better wound healing.CONCLUSION: These data suggest that cyanoacrylate glue is an adequate alternative to conventional sutures to close the surgical wound after alveoloplasty, and better than are 3-0 silk sutures.

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.

Impact of Virtual Planning on Surgical Reposition of the Premaxilla Using an Endonasal Approach and Simultaneous Alveoloplasty.

OBJECTIVE: Describe the surgical repositioning of the premaxilla using an innovative minimally invasive endonasal approach and secondary bone graft at the same time. We want to emphasize the importance of virtual surgical planning in this technique. MATERIAL AND METHODS: A total of 6 patients with bilateral complete cleft lip and palate underwent a surgical repositioning of the premaxilla. Virtual surgical planning was performed in all cases. The ages varied between 8 and 12 years and all were male. Five patients were in the mixed dentition phase and 1 patient was in the definitive phase. Three of the patients had been prepared with presurgical nasoalveolar molding. The other 3 were not prepared for various reasons. All patients had primary repair of cleft lip and palate. INTERVENTIONS: An innovative minimally invasive endonasal approach is presented that has allowed a safe 3-D reposition of the premaxilla in patients with bilateral cleft palate. A simultaneous secondary alveoloplasty with the use of absorbable osteosynthesis is a good choice to achieve symmetry and stability. CONCLUSIONS: Virtual surgical planning is an exceptional instrument to make an appropriate presurgical selection of the patients in which combine the 2 procedures.

Implant treatment on anterior cross-bite of a patient who had orthognathic surgery 20 years ago / 대한치과보철학회지

Orthognathic surgery of skeletal Class III malocclusion improves oral function and facial appearance. The greater amount of skeletal discrepancy, the greater amount of teeth movement required for decompensation, and this often causes pathological changes in periodontal tissue especially in lower anterior dentition. We made a Top-Down treatment plan with personalized analysis using Face Hunter, Plane System and ARCUS Digma II, in order to resolve severe mobility and cross-bite of lower anterior teeth for 49-year-old female patient who had undergone orthognathic surgery 20 years ago due to skeletal Class III malocclusion and mandibular prognathism. Lower anterior teeth were extracted and alveoloplasty was done. After healing of the wound, immediate loading was conducted immediately after implant placement. Final restorations were fabricated Zirconia using CAD/CAM, and inserted intraorally screw-retained type. During 6-month follow-up, no abnormal episodes of restorations were observed, and obtained satisfactorily both of functional and esthetic outcomes.

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?

Initial experiences with NAM-assisted primary repair of the BCLP deformity.

BACKGROUND: Primary surgical repair of the bilateral cleft lip and palate (BCLP) deformity is challenging. Infant Orthopedic (IO) procedures are often used to assist surgical reconstruction of normal anatomy. Nasoalveolar molding (NAM) is a presurgical infant orthopedic procedure that attempts to reduce the cleft nasal deformity, in addition to the lip and alveolus, leading to an esthetic primary surgical repair. OBJECTIVE: NAM provides the surgical team with a better foundation for an easier and more esthetic single stage repair at the level of nose in addition to the lip and alveolus. METHOD: Infant nasal cartilages are amenable to correction with NAM in the first few weeks of infancy when they retain their plasticity. NAM-assisted surgical repair of a complete BCLP infant is discussed. Postoperatively nasal stents were used to retain results and minimize relapse. RESULTS: NAM helped correct premaxillary deviation and protrusion, reduce alveolar cleft width and improve the nasal morphology prior to surgery in the BCLP infant. CONCLUSIONS: NAM helped reduce the severity of the cleft deformity in the BCLP infant and facilitated an easier and esthetic single stage primary surgical 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.

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.