Using the Dermal Fat Graft as a Barrier Membrane in Unilateral Alveolar Cleft Grafting: A Randomized Clinical Trial.

INTRODUCTION: Alveolar cleft grafting is a surgical procedure that usually suffers from inferior results. METHODOLOGY: The patients were divided into 2 groups; study and control. In the study group, the grafted site was covered with a dermal fat graft. RESULTS: Showed that the bone fill percentage (Bergland Scale) recorded in the study was significantly better ( P =0.03); the study group had 14 successful cases out of 18 compared with the control, which had only 9 out of 20. The study group significantly ( P = 0.002) better bone fill (71%±32%) compared with the control (46%±33%). There was a significant reduction in dehiscence in the study compared with the control ( P =0.02); the study group had no dehiscence compared with the control, which had 5 dehiscence. CONCLUSION: The dermal fat graft use as a barrier membrane was successful in improving alveolar cleft grafting.

The Use of Combined Microplate And Miniplate in the Fixation of the Mandibular Fractures (A Randomized Clinical Trial).

The study group patients have been treated with 1.6 microplates at the superior border and 2.0 miniplate at the inferior border to evaluate its efficacy in the fixation of symphyseal and parasymphyseal fractures using this technique. The control patients were treated with two 2.0 plates. The stability was assessed using computed tomography immediately performed postoperatively and after 6 months. Assessment of the change in the intercanine distance using the Student T test was statistically Non Significant ( P value 0.34). The change of intercanine distance in the study was 0.04 ± 0.05 mm, compared with that of the control, which was 0.01 ± 0.03 mm. Assessment of change in intermental foramina distance was statistically NS ( P value = 0.06). The average difference in intermental foramina distance in the study was 0.04 ± 0.05 mm, compared with the control, which was 0.002 ± 0.004 mm. Based on the findings of the current study, the authors recommend the use of microplates combined with miniplates in the correction of both symphyseal and parasymphyseal fractures successfully.

Treatment algorithm for velopharyngeal dysfunction in patients with cleft palate: a systematic review.

The aim of this study was to review current literature regarding the speech outcome of different techniques of surgical treatment of VPD in cleft patients, in an attempt to reach a treatment algorithm. A systematic review was done, by searching Pubmed, Scopus, and Web of Science electronic databases, following the PRISMA guidelines. Articles reporting speech assessment results of secondary VPI surgeries on non-syndromic patients with CP. Surgical techniques were categorised into two groups; palatal and pharyngeal surgeries. Raw data were extracted to compare speech outcome and complication of each technique, with special emphasis on the factors affecting the patients' selection for each technique. Our results showed comparable success and complication rates among these techniques. However, the factors governing selection of each technique were identified and taken into consideration to reach a preliminary algorithm. A preliminary treatment algorithm is described based on the results of our review; the most important factors affecting the technique choice are: VP gap size, LVP position, palatal mobility, palatal scarring, VP closure pattern, and age of the patient.

A rare complication of hemolacria after Le fort I osteotomy: a case presentation.

BACKGROUND: Nasolacrimal duct obstruction (NDO) is a common pathology preventing the proper drainage of the tears, and its main symptom is epiphora. Secondary acquired nasolacrimal duct obstruction (SANDO) can be due to a variety of causes including infection, trauma, or neoplasms. It has been reported to occur with different forms of maxillofacial trauma, especially Le Fort II, Le Fort III, naso-orbital-ethmoidal, and orbital floor fractures. CASE PRESENTATION: A 20-year-old Egyptian female presented to correct a facial disharmony due to a cleft lip and palate defect. The patient reported a history of congenital NDO and had deficient lateral nasal walls. Bimaxillary surgery was planned, including a Le Fort I osteotomy for the maxilla and bilateral sagittal split osteotomy for the mandible. The surgery was uneventful, but the patient complained from bloody tears or hemolacria few days postoperatively. This complication began to cease spontaneously after 2 days and completely recovered after 4 days. CONCLUSION: Hemolacria is an infrequent finding after maxillofacial surgeries and may be associated with CLP surgeries more than other surgeries. In this case, it was easily managed, and surgeons should be more aware of it to try to prevent its occurrence.

The correction of asymmetry using computer planned distraction osteogenesis versus conventional planned extra-oral distraction osteogenesis: A randomized control clinical trial.

The aim of the current study was to evaluate the effect of the use of computer-guided surgical templates in association with mandibular distraction osteogenesis to correct mandibular asymmetry. In the study group a simulation process was conducted to restore the exact position of the chin skeletally by planning the osteotomy orientation, distractor vector, pin positions, and distraction distance calculation. The Control group was treated with conventional distraction in which an oblique osteotomy was done, and distraction was performed until the midline coincided. Patients were randomly allocated into two groups, study and control. The study included (12) young patients; ten males participated and two females (average age 14 ± 6 years) (Range = 6-23 years)). There was a statistically significant (P = 0.02) improvement in smile orientation in the study with 63.7% ± 19% improvement compared to control, which had only 37% ± 14%. There was a statistically significant (P = 0.02) improvement in ramus height in the study with 93% ± 9% improvement compared to control, which had only 74% ± 16%. There was a non-significant (P = 0.2) improvement in chin deviation in the study with 42% ± 26% improvement compared to control, which had only 25% ± 15%. The secondary outcome results showed that there was statistically significant (P = 0.0001) improvement in smile orientation post distraction 50% ± 21%, there was statistically significant (P= P=0.002) improvement of ramus height post distraction osteogenesis 82% ± 16%, and there was statistically significant (P = 0.0001) improvement in chin deviation 33% ± 22% post distraction osteogenesis. Overall, the current research recommends the use of computer planned distraction instead of conventional planned distraction in order to achieve better symmetry. Distraction failed in correction of chin asymmetry; thus, the authors recommend performing genioplasty post distraction after the patient reaches puberty for more optimum results regarding the chin.

The Effect of Bone Marrow Aspirate Concentrate Application on Distracted Bone Biomechanical Properties.

BACKGROUND: This study was conducted to assess effect of bone marrow aspirate concentrate (BMAC) on enhancing biomechanical properties of distraction osteogenesis (DO). METHODS: Twelve rami of goats had distraction and were divided into test group (DO bone supplemented with BMAC) and control group. RESULTS: Assessment of bone-width showed nonsignificant (P = 0.9) increase in test group (mean = 5.3 mm, standard deviation = 1.9 mm) compared to control group (mean = 5.2 mm, standard deviation = 0.8 mm). Assessment of radiographic density showed nonsignificant (P = 0.5) increase in test group (mean = 163.4 Hounsfield Unit, standard deviation = 6.5 Hounsfield Unit) compared to control group (mean = 156.6 Hounsfield Unit, standard deviation = 21.8 Hounsfield Unit). Histomorphometry of mature-bone % showed significant (P = 0.02) increase in test group (mean = 30%, standard deviation = 9.8%) compared to control group (mean = 15.9%, standard deviation = 7.2%). Assessment of biomechanical testing (bone strength) by 3-point bending test showed nonsignificant (P = 0.7) increase in test group (mean = 511.6 Newton, standard deviation = 189.1 Newton) compared to control group (mean = 467.8 Newton, standard deviation = 201.1 Newton). CONCLUSION: The BMAC failed to improve both bone quantity and biomechanical bone strength of distracted bone.

Novel Technique and Step-by-Step Construction of a Computer-Guided Stent for Mandibular Distraction Osteogenesis.

INTRODUCTION: Distraction osteogenesis is an integral part in management of mandibular defects associated with hemifacial microsomia and post-ankylotic mandibular defects. The most difficult part in distraction osteogenesis is the prediction of distraction vector and risk of injury to vital structures as inferior alveolar. The present study aimed to present 3-dimensionally constructed computer-guided splints in distraction osteogenesis to get an ideal vector and minimal risk of vital structures injury. MATERIAL AND METHODS: The technical note presents cases series of 6 patients who had computer-guided distraction osteogenesis surgery using prefabricated splints. RESULTS: The distance between the virtual and physical pins and osteotomy was measured, and the deviation of the vector angle and osteotomy angle was also assessed. Average deviation in pin distance was 3 mm and in vector angle 13.5°. Average deviation in osteotomy distance was 2.6 mm and in osteotomy angle 14.4°. None of the cases had injury to vital structure. There was significant improvement (P = 0.0078) in the medial canthus-buccal commissure distance where the arithmetic mean improved from 59.6 (SD = 10.1) mm pre-distraction in the defective side to 67.1 (SD = 8) mm post-distraction. The degree of correction was 97% compared to the normal side. CONCLUSION: 3D printed surgical stents were successful in transferring the virtual treatment plan of mandibular distraction osteogenesis into the surgical theatre with an acceptable margin of error and without injury to any vital structures.

The Effect of Bone Marrow Mesenchymal Stem Cells Application on Distracted Bone Quality during Rapid Rate of Distraction Osteogenesis.

Distraction osteogenesis (DO) bone regenerate usually suffers from an inferior quality especially with rapid rate. This study was conducted to investigate the effect of mesenchymal stem cells (MSCs) application on different rates of distraction bone quality. Twenty-four goats were divided into group A with standard DO and group B with rapid distraction osteogenesis (RDO) both aided by MSCs. Group C with standard DO and group (D) with RDO were controls. Kruskal-Wallis test and Conover's post hoc analysis was used to evaluate significance ( p = 0.05). Histomorphometry showed a strongly significant (SS) increase ( p = 0.00036) in trabecular bone (TB) in group A (TB = 174.7 µm, SD = 33.5) and group B (TB = 166.8 µm, SD = 14) compared with group C (TB = 115.4 µm, SD = 19.6) and group D (TB = 86.1 µm, SD = 9.3). There was SS decrease ( p = 0.00093) in osteoid percentage (OP) in group A (OP = 13.4%, SD = 2) and group B (OP = 11.5%, SD = 6.5) compared with group C (OP = 27.3, SD = 3.5) and group D (OP = 26.2%, SD = 2.6). Energy dispersive X-ray showed a nonsignificant increase ( p = 0.11) in calcification (Ca 2+ %) in group A (Ca 2+ % = 17.6%, SD = 4.9) and group B (Ca 2+ % = 17.6%, SD = 4.3) compared with group C (Ca 2+ % = 14.2%, SD = 6.7) and group D (Ca 2+ % = 11.5%, SD = 2.4). MSCs application improved microscopic bone quality during standard DO and RDO. However, macroscopic bone quality improvement still needs further investigation.

Cone Beam Computed Tomography Analysis of Oropharyngeal Airway in Preadolescent Nonsyndromic Bilateral and Unilateral Cleft Lip and Palate Patients.

OBJECTIVE: The objective of this study was to assess the volume, area, and dimensions of the oropharyngeal airway (OPA) in a previously repaired nonsyndromic unilateral cleft lip and palate (UCLP) versus bilateral cleft lip and palate (BCLP) patients when compared with noncleft controls using cone beam computed tomography (CBCT). DESIGN: This was a retrospective case-control study. SETTING: The Cleft Care Center and outpatient clinic that are affiliated to our faculty were the settings for the study. PARTICIPANTS: A total of 58 CBCT scans were selected of preadolescent individuals: 14 BCLP, 20 UCLP, and 24 age- and gender-matched noncleft controls. VARIABLES: Variables were volume, cross-sectional area (CSA), midsagittal area (MSA), and dimensions of OPA. STATISTICAL ANALYSIS: One-way analysis of variance and post hoc tests were used to compare variables. Statistical significance was set at P ≤ .05. RESULTS: UCLP showed significantly smaller superior oropharyngeal airway volume than both controls and BCLP ( P ≤ .05). BCLP showed significantly larger CSA at soft palate plane and significantly larger MSA than both UCLP and controls ( P < .05). CONCLUSIONS: UCLP patients at the studied age and stage of previously repaired clefts have significantly less superior oropharyngeal airway volume than both controls and BCLP patients. This confirms that preadolescents with UCLP are at greater risk for superior oropharyngeal airway obstruction when compared with those BCLP and controls. Furthermore, BCLP patients showed significantly larger CSA at soft palate plane and MSA than both controls and UCLP patients. These variations in OPA characteristics of cleft patients can influence function in terms of respiration and vocalization.

Cone-Beam Computed Tomography Analysis of the Nasopharyngeal Airway in Nonsyndromic Cleft Lip and Palate Subjects.

OBJECTIVE: To assess the nasopharyngeal airway volume, cross-sectional area, and depth in previously repaired nonsyndromic unilateral cleft lip and palate versus bilateral cleft lip and palate patients compared with noncleft controls using cone-beam computed tomography with the ultimate goal of finding whether cleft lip and palate patients are more liable to nasopharyngeal airway obstruction. DESIGN: A retrospective analysis comparing bilateral cleft lip and palate, unilateral cleft lip and palate, and control subjects. Significance at P ≤ .05. SETTING: Cleft Care Center and the outpatient clinic that are both affiliated with our faculty. PARTICIPANTS: Cone-beam computed tomography data were selected of 58 individuals aged 9 to 12 years: 14 with bilateral cleft lip and palate and 20 with unilateral cleft lip and palate as well as 24 age- and gender-matched noncleft controls. VARIABLES: Volume, depth, and cross-sectional area of nasopharyngeal airway were measured. RESULTS: Patients with bilateral cleft lip and palate showed significantly larger nasopharyngeal airway volume than controls and patients with unilateral cleft lip and palate (P < .001). Patients with bilateral cleft lip and palate showed significantly larger cross-sectional area than those with unilateral cleft lip and palate (P < .001) and insignificant cross-sectional area compared with controls (P > .05). Patients with bilateral cleft lip and palate showed significantly larger depth than controls and those with unilateral cleft lip and palate (P < .001). Patients with unilateral cleft lip and palate showed insignificant nasopharyngeal airway volume, cross-sectional area, and depth compared with controls (P > .05). CONCLUSIONS: Unilateral and bilateral cleft lip and palate patients did not show significantly less volume, cross-sectional area, or depth of nasopharyngeal airway than controls. From the results of this study we conclude that unilateral and bilateral cleft lip and palate patients at the studied age and stage of repaired clefts are not more prone to nasopharyngeal airway obstruction than controls.

Effect of Mesenchymal Stem Cell Application on the Distracted Bone Microstructure: An Experimental Study.

PURPOSE: Distraction osteogenesis (DO) is a surgical technique used to regenerate bone. The aim of this study was to improve bone quality and quantity during DO by the addition of mesenchymal stem cells (MSCs). MATERIALS AND METHODS: The study was conducted on 12 goats assigned to a study group or a control group. In the study group, DO was aided with MSCs. Bone quality was assessed using energy dispersive x-ray (EDX), a scanning electron microscope (SEM), and histology. The histologic assessment was performed by measuring trabecular bone (TB) thickness in sections stained with hematoxylin and eosin (H&E) and by measuring osteoid bone percentage in sections stained with Masson trichrome (MT). RESULTS: EDX showed an increase in calcification in the study group (mean Ca(2+), 17.58%; standard deviation [SD], 4.9%) compared with the control group (mean Ca(2+), 14.17%; SD, 6.7%). However, the increase was not statistically significant (P = .3354). Histomorphometric analysis of the H&E samples showed an increase in TB size in the study group (mean TB, 174.7 µm; SD, 33.5 µm) compared with the control group (mean TB, 115.4 µm; SD, 19.6 µm), and the increase was highly statistically significant (P = .0039). Analysis of the MT samples showed a decrease in osteoid percentage (mean osteoid percentage, 13.4%; SD, 2%) in the study group compared with the control group (mean osteoid percentage, 27.3%; SD, 3.5%). The decrease in osteoid percentage was statistically significant (P = .0001), indicating more rapid healing in the study group compared with the control group. CONCLUSION: MSCs improved the bone quality of distracted bone and increased the crystal density in SEM images of the study group compared with that of the control group. MSCs showed promising results in improving the quality and quantity of distracted bone.

Acellular dermal matrix allograft: An effective adjunct to oronasal fistula repair in patients with cleft palate.

CONTEXT: Oronasal fistula (ONF) following cleft palate (CP) repair are a challenging problem associated with high recurrent rates. Acellular dermal matrix allograft is an available tissue substitute. AIMS: The aim of this study was to evaluate the effectiveness of acellular dermal matrix in the repair of ONF associated with CP that is recurrent or larger than 15 mm in any dimension. SETTINGS AND DESIGN: This is a prospective study where 12 patients with repaired CP suffering from ONF of the hard palate >15 mm in diameter were included. MATERIALS AND METHODS: Age ranged from 12 to 25 years. Acellular dermal matrix was firmly secured between repaired oral and nasal mucosal layers. Patients were clinically followed-up for 6 months postoperatively to assess total time for complete healing, dehiscence and/or refistulaization. STATISTICAL ANALYSIS USED: Fisher's exact test. RESULTS: Acellular dermal matrix was integrated with successful fistula closure in all except 1 patient where failure of graft integration was noticed early postoperatively. In 6 patients, the oral mucosal layer showed dehiscence, through which the graft was exposed. Graft integration extended from 4 to 12 weeks postoperatively during which patients were instructed to follow a soft diet and meticulous oral hygiene measures. CONCLUSIONS: Acellular dermal matrix allografts are safe and effective adjuncts for use in closure of ONF in the hard palate that is recurrent or larger than 15 mm in any dimension.

Premaxillary characteristics in complete bilateral cleft lip and palate: A predictor for treatment outcome.

OBJECTIVES: The aim of the current study was to investigate how bilateral cleft lip and palate (BCLP) cases responded differently to presurgical orthopedics (PSO) and primary lip repair (LR) based on premaxillary characteristics. We suggest a clinically oriented descriptive classification for BCLP based on premaxillary characteristics. DESIGN AND SETTING: A retrospective longitudinal comparative study where available records of all non-syndromic patients with complete BCLP attending the Cleft Clinic, affiliated to the Oral and Maxillofacial Surgery department, Ain-Shams University, Cairo, Egypt were assessed. SAMPLE POPULATION AND METHODOLOGY: Twenty-two cases were collected over a 4-years period from 2008 to 2011 (15 boys and 7 girls). Model assessment was performed for serial models representing four stages of treatment; M1: Prior to start of PSO, M2: At the end of PSO, M3: One month after LR, M4: Three months after LR. The premaxillary and vomerine widths were measured on M1. Models (M1-M4) were assessed for changes in anteroposterior projection, anterior arch width, intercanine width and posterior arch width and results were statistically analyzed. Intra-and postoperative surgical findings during and after primary LR were recorded. The sample was divided into two groups based on the premaxillary size and characteristics; Group R: Rudimentary premaxilla and Group P: Prominent premaxilla. RESULTS: There was a highly significant difference in premaxillary width between the two groups (P = 0.00), changes in anteroposterior projection of the premaxilla were significant one and three months after LR. Changes in maxillary anterior arch width, intercanine and posterior arch widths were non-significant between groups. Mean age difference between the two groups was only statistically significant at the stage of LR. Surgical differences were noted between the two groups. Postoperatively as compared to group R; group P showed more premaxillary bulge and show at rest, as well as more prolabial stretching. In addition, facial profile was more convex in group P. CONCLUSION: The two types of BCLP outlined in this study are different from several aspects, and hence management should be modified according to each case. This descriptive classification provides a useful tool for evaluation and planning of patients with BCLP.