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.

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.

Comprehensive repair of the alveolar cleft using cortical and cancellous bone layers: A retrospective study.

To retrospectively review the clinical effect of comprehensive treatment of alveolar cleft (CTAC) using the mandible as the bone source. Patients with alveolar clefts who met the inclusion criteria were subjected to a CTAC protocol that included the following: (1) preoperative orthodontic treatment for creating good soft-tissue conditions; (2) 'area-like grafting' with subperiosteal osteogenic chin bone instead of cartilaginous osteogenic iliac bone; (3) simulation of normal bone anatomy via a sandwich-like bone graft consisting of 'cortical bone + cancellous bone + cortical bone'; and (4) strong internal fixation to ensure initial bone block stability. At 6 months postoperatively, the titanium plate was removed and cone-beam computed tomography was performed to evaluate the surgical results. A total of 54 patients underwent treatment with the CTAC protocol. The average age at the initial operation was 10.3 ± 2.1 years, and the average hospital stay was 2.8 ± 0.6 days. At 6 months postoperatively, 49 patients (90.7%) showed good clinical results. The transplanted bone block formed a 'cortical bone + cancellous bone + cortical bone' structure similar to that of the normal jawbone. A mature bone bridge formed, and the impacted permanent teeth continued to erupt and enter the bone graft area. CTAC is a comprehensive restorative solution for alveolar cleft repair that integrates multiple concepts, including orthodontics, embryology, anatomy, and improvements to surgical methods. The method is easy to perform, causes little surgical trauma, and shows a stable success rate, and is thus worth promoting.

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.

Effect of adjuvant autologous platelet concentrates on secondary repair of alveolar clefts: A systematic review and meta-analysis.

OBJECTIVE: To review the existing evidence on the adjuvant use of autologous platelet concentrates (APCs) with iliac crest bone graft (ICBG) in the reconstruction of the secondary alveolar cleft. METHODS: Electronic databases were searched systematically until November 2022. Clinical trials comparing the three-dimensional radiological outcomes of patients who underwent secondary alveolar bone grafting (SABG) with ICBG and APCs to those with ICBG alone and the radiological outcomes assessed 6 months after surgery were included. Two authors performed the study selection and the assessment of the risk of bias. Meta-analysis was performed using the random-effects model to determine the risk ratio (RR) for developing wound dehiscence and the mean difference (MD) with a 95% confidence interval (CI) for the percentage of newly formed bone. RESULTS: Nine studies (seven RCT and two CCT) were included with a low to high risk of bias. At the 6-month follow-up, the study group revealed insignificant results regarding the percentage of newly formed bone (MD = 6.49; 95% CI: -0.97, 13.94; p = .09; χ2  = 0.01; I2  = 71%). In addition, the overall risk of developing wound dehiscence was lower in the study group (RR = 0.34; 95% CI: 0.15, 0.78; p = .01; χ2  = 0.67; I2  = 0%). CONCLUSION: Currently, there is insufficient evidence to support the adjuvant use of APCs with ICBG on enhanced bone regeneration following secondary alveolar bone grafting. However, combining ICBG and APCs might be beneficial in reducing the risk of developing wound dehiscence.

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.

Alveolar cleft reconstruction utilizing a particulate autogenous tooth graft and a novel split-thickness papilla curtain flap - A retrospective study.

During secondary alveolar cleft grafting, the use of autogenous cancellous bone harvested from the iliac crest is still considered the gold standard. Due to the risk of donor-site morbidity and excessive graft resorption, alternative grafting materials (e.g. intraoral bone, xenografts) have been tested. Autogenous tooth bone graft (ATB) is a novel material derived from extracted teeth. ATB has successfully been used in pre-prosthetic and periodontal surgery for hard-tissue reconstruction. Seven patients with unilateral cleft lip and palate were treated with ATB, using their own deciduous teeth for grafting. Defects were accessed utilizing a novel split-thickness papilla curtain flap. Cone-beam computed tomography scans were taken prior to and 3 months following cleft surgery to assess graft integration, graft stability, and the volume of the newly formed hard tissues. Hard-tissue gain, as measured at the 3-month follow-up, averaged 0.65 cm3 ± 0.26 cm3. Results showed acceptable graft integration and stability at the 3-month follow-up, with no adverse effects or excessive resorption of the graft. The use of ATB might be a feasible alternative for alveolar cleft grafting. However, long-term studies using a large sample size are required to derive further conclusions.

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.

Bioglass 45S5, a relevant alternative to autogenous harvesting for secondary alveolar bone grafts in clefts? Retrospective study of one hundred surgeries.

The secondary alveolar bone grafting (SABG) step restores the continuity of the alveolar bone necessary for dentition. Faced with the complications of autografts, synthetic biomaterials such as Bioglass (BG) 45S5 have been proposed. The objective was to evaluate the success rate of SABG with the addition of BG 45S5 and to highlight the prognostic factors. Patients who underwent operation between 2015 and 2021 and had follow-up cone-beam computed tomography (CBCT) were analyzed. Multivariate analysis was performed to determine factors influencing radiographic success. A total of 102 SABG were analyzed. They were unilateral total cleft lip and palate (49, 48.0%). The mean age at surgery was 9.32 ± 3.09 years. Surgeries were performed mainly outside a syndromic context and without a family history after orthodontic preparation. The radiographic success rate at 1 year was 80.4%. Mixed dentition stage (odds ratio [OR] = 7.3, p = 0.024), absence of syndromic context (OR = 20.7, p = 0.024) and female sex (OR = 4.88, p = 0.021) were factors predictive of surgical success. The use of BG 45S5 instead of autograft is relevant for SABG, with a 1-year success rate of over 80%. The stage of mixed dentition, the absence of syndromic context, and female sex were factors for good prognosis.

Influence of osseous structure characteristics of unilateral alveolar cleft on outcomes of alveolar bone grafting: a retrospective study.

BACKGROUND: To enhance the success rate of alveolar bone grafting, it is crucial to identify the factors that may influence the postoperative bone formation. This study aimed to investigate the impact of various osseous structure characteristics of alveolar clefts on the survival ratio of autogenous cancellous bone particle grafts. METHODS: A retrospective study was conducted on 60 patients who underwent surgery performed by the same surgeon between 2016 and 2022. Two researchers measured and recorded the bone defect volume (DV), postoperative bone formation volume at 1 year, contact area between the graft and the bone surface within the cleft (S), cleft width (CW), osseous occlusion relationships, and presence of a cleft palate and initial bone bridge within the cleft for each patient. Pearson correlation analysis, Spearman's correlation analysis, and multiple linear regression analysis were performed. RESULTS: The analysis results revealed statistical correlations between DV, CW, ratio of S to DV, cleft palate, initial bone bridge presence, and occlusion relationships with the survival rate. Multiple linear regression analysis showed that initial bone bridge and occlusion relationships affected the graft survival rate. CONCLUSIONS: Based on the presence of initial bone bridges and occlusions, we can make a rough estimate of the postoperative bone formation outcome in patients. However, the underlying mechanisms by which these two factors influence the bone formation require further investigation. In addition, preoperative orthodontic treatment to improve occlusal relationships may improve the postoperative bone formation outcomes in alveolar bone grafting.

Regeneração óssea guiada para aumento horizontal de rebordo utilizando fibrina rica em plaquetas associada a enxertos ósseos: revisão de literatura / Guided bone regenerationfor horizontal bone augmentation using platelet- rich fibrin associated with bone grafts: literature review

Objetivo: revisar a literatura sobre os diferentes tipos de derivados de plaquetas autólogas e o desempenho clínico do uso do sticky bone para aumento ósseo horizontal de rebordo. Materiais e métodos: Para realização dessa revisão foram realizadas buscas nas bases de dados PubMed, Google Scholar e Web of Science, utilizando os seguintes descritores: "platelet-rich fibrin" AND "sticky bone" OR "alveolar bone grafting" AND "sticky bone" OR "guided bone regeneration" AND "sticky bone" AND "alveolar ridge augmentation" OR "Alveolar ridge augmentation" AND "sticky bone". Foram incluídos artigos publicados em inglês, que abordavam conceitos relacionados aos agregados plaquetários e a regeneração óssea guiada para aumento ósseo horizontal de rebordo utilizando fibrina rica em plaquetas associada à enxertos ósseos (sticky bone). Resultados: Após avaliação dos estudos encontrados foram selecionados 11 artigos sobre o uso do sticky bone para aumento horizontal de rebordo. Para compor este trabalho foram selecionados também 14 estudos de revisão e artigos associados ao tema. Por ser de fácil aplicação e obtenção, muitos autores têm estudado as aplicações cirúrgicas do sticky bone e os resultados demonstram que o aumento horizontal do rebordo utilizando essa técnica pode ser realizado de forma previsível. Conclusão: apesar de haver estudos promissores sobre o uso do sticky bone, falta evidência na literatura sobre seu sucesso clínico. Assim, para compreender o potencial regenerativo desta técnica são necessários um maior número de estudos randomizados, com diferentes materiais de enxerto e protocolos padronizados de obtenção do sticky bone.(AU)

Objective: to review the literature on the different types of autologous platelet derivatives and the clinical performance of using sticky bone for horizontal bone ridge augmentation. Materials and methods: In order to conduct this review, it was conducted searches in the PubMed, Google Scholar, and Web of Science databases using the following descriptors: "platelet-rich fibrin" AND "sticky bone" OR "alveolar bone grafting" AND "sticky bone" OR "guided bone regeneration" AND "sticky bone" AND "alveolar ridge augmentation" OR "Alveolar ridge augmentation" AND "sticky bone". It included articles published in English that addressed concepts related to platelet aggregates and guided bone regeneration for horizontal bone augmentation using platelet-rich fibrin associated with bone grafts (sticky bone). Results: After evaluating the studies found, were selected 11 articles on the use of sticky bone for horizontal ridge augmentation. To compose this work, 14 review studies and articles associated with the topic were also selected. Due to its ease of application and availability, many authors have explored the surgical applications of sticky bone, and the results indicate that horizontal ridge augmentation using this technique can be predictably performed. Conclusion: while there are promising studies on the use of sticky bone, the literature lacks evidence regarding its clinical success. Therefore, to fully understand the regenerative potential of this technique, further randomized studies are needed, involving different graft materials and standardized protocols for obtaining sticky bone.(AU)

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.

Effectiveness of iliac cancellous bone grafting in alveolar cleft repair and analysis of factors affecting it.

OBJECTIVES: To review the effectiveness of secondary alveolar bone grafting using iliac cancellous bone in patients with unilateral complete alveolar cleft and to investigate the factors influencing it. METHODS: A retrospective study of 160 patients with unilateral complete alveolar clefts who underwent iliac cancellous bone graft repair at the Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, was conducted. Eighty patients in the young age group (6-12 years) and 80 in the old age group (≥13 years) were included. Bone bridge formation was determined using Mimics software, and the volume was measured to calculate the iliac implantation rate, residual bone filling rate, and resorption rate. The factors that affected bone grafting in both subgroups were investigated. RESULTS: Using bone bridge formation as the clinical success criterion, the success rate for the entire population was 71.25%, with a significant difference of 78.75% and 63.75% for the young and old age groups, respectively (P=0.036). The gap volume in the latter was significantly larger than that in the former (P<0.001). The factors that influenced bone grafting in the young group were the palatal bone wall (P=0.006) and history of cleft palate surgery (P=0.012), but only the palatal bone wall affected the outcome in the old age group (P=0.036). CONCLUSIONS: The results of alveolar bone grafting for the old age group were worse than those for the young age group. The palatal bone wall was an important factor that affected alveolar bone grafting, and alveolar bone grafting in the young patients was influenced by the history of cleft palate surgery.

Effect of body mass index on progressive bone mineral density in patients with cleft after secondary alveolar bone grafting.

BACKGROUND: Although childhood obesity matters, the association between body mass index (BMI) and bone mineral density (BMD) progression in grafted tissue after secondary alveolar bone grafting (ABG) for children with cleft alveolus is scarcely studied. Accordingly, this study explored the influence of BMI on BMD progression after ABG. METHODS: In total, 39 patients with cleft alveolus receiving ABG at the mixed dentition stage were enrolled. Patients were classified as underweight, normal weight, or overweight or obese according to age- and sex-adjusted BMI. BMD was measured in Hounsfield units (HU) from cone-beam computed tomography scans obtained 6 months (T1) and 2 years (T2) postoperatively. Adjusted BMD (HUgrafted tissue/HUpogonion, BMDa) was used for further analysis. RESULTS: For underweight, normal-weight, and overweight or obese patients, BMDaT1 values were 72.87%, 91.85%, and 92.89%, respectively (p = 0.727); BMDaT2 values were 111.49%, 112.57%, and 113.10% (p = 0.828); and density enhancement rates were 29.24%, 24.61%, and 22.14% (p = 0.936). No significant correlation was observed between BMI and BMDaT1, BMDaT2, or density enhancement rates (p = 0.223, 0.156, and 0.972, respectively). For patients with BMI < 17 and ≥ 17 kg/m2, BMDaT1 values were 89.80% and 92.89%, respectively (p = 0.496); BMDaT2 values were 111.49% and 113.10% (p = 0.216); and density enhancement rates were 23.06% and 26.39% (p = 0.573). CONCLUSION: Patients with different BMI values had similar outcomes (BMDaT1, BMDaT2, or density enhancement rate) after our ABG procedure in the 2-year postoperative follow-up.

Two-stage alveolar bone grafting for nasal floor reconstruction in adult cleft patients.

Alveolar cleft is one of the key links of cleft lip and palate reconstruction due to its close relationship with tooth and jaw coordination and nasolabial deformity. The alveolar bone graft repairs the hole in the gum ridge and stabilizes the bone arch, providing better support for the base of the nose and new bone for the roots of the developing teeth to grow into. Unfortunately, bone graft failure in the traditional way, even among minor clefts, bony hypoplasia, or absence that affects the nasal base and piriform rim, is common. Two-stage alveolar bone grafting, which has advantages in addressing the underlying skeleton and deficiency, could be an optional surgical procedure for nasal floor reconstruction in adult patients with a broad alveolar cleft.

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.

The effectiveness of using platelet-rich concentrate with iliac bone graft in the repair of alveolar cleft: a meta-analysis of randomized controlled trials.

The purpose of this study was to review the existing evidence from randomized controlled trials (RCTs) on the effect of autogenous bone grafts combined with a platelet-rich concentrate on alveolar clefts. An electronic search was conducted in the PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov databases for studies published between January 2000 and April 2022. This study included six RCTs to evaluate bone quantity (bone formation ratio, %) and quality (bone density in Hounsfield units, HU), as well as complications as a way to assess the safety of the technique. Two independent reviewers assessed the risk of bias. There was no statistically significant difference in bone formation ratio at 6 months of follow-up between the use of autologous bone alone for alveolar bone grafting or adding platelet-rich plasma (PRP) (mean difference (MD) 14.33%, 95% confidence interval (CI) - 7.19% to 35.85%; P = 0.196) or platelet-rich fibrin (PRF) (MD 9.38%, 95% CI -2.36% to 21.12%; P = 0.123) to autologous bone. The MD for the change in bone density at 6 months was in favour of PRP added to autologous bone graft (MD 155.69 HU, 95% CI 99.29-212.09 HU; P < 0.001); however, this result was based on only two studies, one of which had a high risk of bias. Patients who received autologous bone graft with PRP were significantly less likely to experience complications (odds ratio (OR) 0.21, 95% CI 0.05-0.92; P = 0.038), but this was no longer statistically significant after a sensitivity test (OR 0.24, 95% CI 0.04-1.56; P = 0.138). In conclusion, this systematic review and meta-analysis appears to show no benefit to using a platelet-rich concentrate combined with autologous bone for alveolar cleft grafting in terms of bone volume, bone density, or complications.

Machine learning in 3D auto-filling alveolar cleft of CT images to assess the influence of alveolar bone grafting on the development of maxilla.

BACKGROUND: Machine learning based auto-segmentation of 3D images has been developed rapidly in recent years. However, the application of this new method in the research of patients with unilateral cleft lip and palate (UCLP) is very limited. In this study, a machine learning algorithm utilizing 3D U-net was used to automatically segment the maxilla, fill the cleft and evaluate the alveolar bone graft in UCLP patients. Cleft related factors and the surgery impact on the development of maxilla were analyzed. METHODS: Preoperative and postoperative computed tomography images of 32 patients (64 images) were obtained. The deep-learning-based protocol was used to segment the maxilla and defect, followed by manual refinement. Paired t-tests and Mann-Whitney tests were performed to reveal the changes of the maxilla after surgery. Two-factor, two-level analysis for repeated measurement was used to examine the different trends of growth on the cleft and non-cleft sides of the maxilla. Pearson and Spearman correlations were used to explore the relationship between the defect and the changes of the maxillary cleft side. RESULTS: One-year after the alveolar bone grafting surgery, different growth amount was found on the cleft and non-cleft sides of maxilla. The maxillary length (from 34.64 ± 2.48 to 35.67 ± 2.45 mm) and the alveolar length (from 36.58 ± 3.21 to 37.63 ± 2.94 mm) increased significantly only on the cleft side while the maxillary anterior width (from 11.61 ± 1.61 to 12.01 ± 1.41 mm) and posterior width (from 29.63 ± 2.25 to 30.74 ± 2.63 mm) increased significantly only on the non-cleft side after surgery. Morphology of the cleft was found to be related to the pre-surgical maxillary dimension on the cleft side, while its correlation with the change of the maxilla after surgery was low or not statistically significant. CONCLUSION: The auto-segmentation of the maxilla and the cleft could be performed very efficiently and accurately with the machine learning method. Asymmetric growth was found on the cleft and non-cleft sides of the maxilla after alveolar bone graft in UCLP patients. The morphology of the cleft mainly contributed to the pre-operation variance of the maxilla but had little impact on the maxilla growth after surgery.

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.

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.