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.

Application of the MicroNAPS Classification for Robin Sequence.

OBJECTIVE: The only findings consistent among infants with Robin sequence (RS) are the presence of micrognathia, glossoptosis, and upper airway obstruction (UAO). Feeding and growth dysfunction are typical. The etiopathogenesis of these findings, however, is highly variable, ranging from sporadic to syndromic causes, with widely disparate levels of severity. This heterogeneity has created inconsistency within RS literature and debate about appropriate workup and treatment. Despite several attempts at stratification, no system has been broadly adopted. DESIGN: We recently presented a novel classification that is summarized by the acronym MicroNAPS. Each of 5 elements is scored: Micrognathia, Nutrition, Airway, Palate, Syndrome/comorbidities, and element scores are summarized into a "stage". RESULTS: Testing of this system in a sample of 100 infants from our center found it to be clinically relevant and to predict important management decisions and outcomes. CONCLUSIONS: We herein present an interactive website (www.prscalculator.com) and printable reference card for simple application of MicroNAPS, and we advocate for this classification system to be adopted for clinical care and research.

Can Alveolar Bone Grafting Using Posterior Iliac Crest be a Day Surgery Procedure?

OBJECTIVE: The purpose of this study was to determine if patients undergoing alveolar bone grafting (ABG) can be discharged home on the day of surgery safely and with high satisfaction. DESIGN: This is a prospective cohort study of patients who underwent ABG over a 6-month period (August 2022 to February 2023). Medical records were reviewed, and postoperative surveys were provided to assess patient/family experience. SETTING: Tertiary care free-standing pediatric hospital. PATIENTS AND PARTICIPANTS: Participants who had ABG using iliac marrow from the posterior iliac crest. INTERVENTIONS: Subjects were assigned to overnight admission (ON) or day surgery (DS) based on hospital bed capacity. MAIN OUTCOME MEASURES: Main outcome measures were postoperative medical events and satisfaction with discharge timing. RESULTS: 41 participants were included: ON, n = 20 (48.8%); DS, n = 21 (51.2%), and there were no differences between groups in any predictor variable. There were no postoperative medical events. Overall, families reported comfort managing pain, nausea, bleeding, hydration, and nutrition after discharge. Most (83.3% of the DS group and 69.2% of the ON group, P = .644) reported satisfaction with the discharge timing they received, despite this being driven by hospital rather than patient factors. Reasons for some families preferring longer admission included fluid management (n = 2), anxiety about postoperative swelling (n = 2), and a long drive home (n = 1). For the ON group, 16.7% would have preferred same-day discharge. CONCLUSIONS: Same day discharge is safe and well-received in appropriately selected patients who undergo ABG using posterior iliac crest. Perioperative patient/family education is essential.

Conservative Management of Severe Medication-Related Osteonecrosis of the Jaw With Pathological Fracture.

ABSTRACT: Medication-related osteonecrosis of the jaw (MRONJ) is a well-known risk following dental extraction in patients taking certain medications. Pathological fracture secondary to MRONJ often requires complex operative intervention.This case demonstrates the conservative management of pathological fracture secondary to MRONJ in a patient with multiple comorbidities. The patient developed MRONJ with pathological fracture following extraction of the mandibular second molar. The patient presented with significant surgical risk factors, having hypertension and a recent stroke, causing dense left hemiparesis, subsequently resulting in transition to high-level nursing care. Given the high risk of reconstructive surgery, nonoperative management was undertaken. Following a course of long-term antibiotics with resolution of signs of infection, the case was managed conservatively with chlorhexidine-based mouthwash and soft diet.With routine clinico-radiographic assessment and optimal oral health care, the pathological fracture did not require operative intervention. Healing progressed well with no clinical complications and radiographic evidence of good healing at 6- and 12-month follow-up on orthopantomogram.A role for conservative management of pathological fractures secondary to MRONJ yet exists, especially in the elderly population. This case highlights the importance of developing treatment plans based on individual patient context and clinical assessment.

Tranexamic Acid in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis.

ABSTRACT: Blood loss is a potential cause of morbidity and mortality in craniosynostosis surgery. Recent reports have suggested that the use of tranexamic acid (TXA), an antifibrinolytic agent, mitigates this blood loss. A comprehensive systematic review and subsequent meta-analysis was undertaken, with the view to clarify the effectiveness of TXA in reducing blood loss and transfusion requirements in craniosynostosis surgery. Medline and PubMed databases were searched using the preferred reporting items for systematic reviews and meta-analyses technique, and 7003 articles were assessed based on predefined selection criteria. Seven trials were identified, of which 2 were randomized controlled trials and the remainder retrospective cohort studies. All trials were assessed using the Jadad and strengthening the reporting of observational studies in epidemiology scores. The meta-analysis found a clear statistical reduction in blood loss in those patients who received TXA perioperatively, with a combined blood loss reduction of 7.06 ml/kg (95% confidence interval -8.97 to -5.15, P < 0.00001). The blood loss reduction was found to extrapolate to a reduction in perioperative transfusion requirements by 8.47 ml/kg in this cohort (95% confidence interval -10.9 to -6.04, P < 00001). There were no TXA-related adverse outcomes recorded in the 258 patients who received TXA across all trials. The trials included in this meta-analysis were limited by underpowered population sizes and significant heterogeneity in blood loss recording techniques. Further, there was significant heterogeneity amongst operations performed. The current literature appears to support the use of TXA in craniosynostosis surgery, but further high quality randomized controlled trials are indicated, ideally including a subgroup analysis between the operations performed.

Intravenous Tranexamic Acid is Associated With a Clinically Significant Reduction in Blood Loss in Craniosynostosis Surgery.

ABSTRACT: Blood loss is a potential cause of morbidity and mortality in craniosynostosis surgery. Recent reports have suggested that the use of tranexamic acid (TXA), an antifibrinolytic agent, mitigates this blood loss. A retrospective cohort study of patients undergoing craniosynostosis surgery at a tertiary craniofacial hospital in Sydney was undertaken. Primary outcomes were blood loss and transfusion requirements. Two groups were compared: those who received intravenous prophylactic TXA and those who underwent surgery without TXA. Statistical analysis was performed with Student t test and the Mann-Whitney U test for nonparametric results. We identified 206 patients who underwent craniosynostosis surgery over an 8 year period; 78 control patients and 128 patients that received TXA. Tranexamic acid was found to result in a weight-adjusted calculated blood loss mean difference of 9.6 ml/kg across all procedures (P = 0.0332 95% confidence interval 0.7734-18.4266). The actual blood loss reduction achieved with TXA was 6.7 ml/kg in spring cranioplasties, compared to 15.2 ml/kg in fronto-orbital remodeling procedures. There was a statistically and clinically significant reduction in postoperative transfusion incidence, with transfusions required in 27% of controls and 6% of TXA patients (P < 0.0001). The number needed to treat to prevent giving a unit of blood postoperatively was 4.8. There were no incidences of TXA-specific complications. This study found that TXA is a safe and effective method of decreasing blood loss and transfusion requirements in patients undergoing craniosynostosis surgery. The clinical benefit of TXA is particularly evident in the more invasive craniosynostosis surgeries.

Recurrent odontogenic keratocyst with orbital invasion.

Odontogenic keratocysts (OKCs) are aggressive lesions that have been variously classified as neoplasms or cysts according to the World Health Organisation (WHO). They can be challenging to surgically remove and the cysts can exhibit locally aggressive behaviour if incompletely excised. We describe a case of recurrent OKC invading the orbit requiring multidisciplinary approach for extended surgical excision, and review the current literature regarding this condition.

Patient-specific Le Fort I Osteotomy Plates are More Stable than Stock Plates in Patients with Cleft Lip and Palate.

BACKGROUND: There is evidence that patient-specific plate fixation for Le Fort I osteotomies (LFI) is more stable than traditional plates. The purpose of this study was to evaluate stability of LFI in patients with cleft lip and palate (CLP) and determine stability differences between patient-specific and stock plates. METHODS: Consecutive patients with CLP who underwent isolated LFI by one surgeon (BLP) between 2016 and 2021 were included. The predictor variable was type of plate used for fixation (patient-specific or stock). The outcome variable was magnitude of relapse in the vertical (Nasion-A point) and horizontal planes (Basion-A point) at one year post LFI using 3-dimensional cone beam computed tomography. Statistical analysis included Independent Samples T-test, Mann-Whitney U, Fisher's exact and Chi-square tests. P<0.05 was significant. RESULTS: The sample included 63 subjects; 23 (36.5%) in the patient-specific group and 40 (63.5%) in the stock group. Groups were comparable by sex, race, age at operation, cleft type, presence of pharyngeal flap and magnitude of horizontal movement (P>0.136, all). Subjects who underwent patient-specific plate fixation were less likely to have ≥1mm change at one year in the horizontal (4.3% vs. 50.0%, p<.001) and vertical planes (4.3% vs. 65.0%, P<.001) compared to stock plates. For patients who had >10mm horizontal advancement, the patient-specific plates had significantly less relapse (patient-specific 0.105mm ± 0.317mm vs. stock 1.888mm ± 1.125mm vs, P=.003). CONCLUSIONS: Patient-specific plate fixation of LFI is more stable and demonstrates less relapse after one year than stock plates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

MicroNAPS: A Novel Classification for Infants with Micrognathia, Robin Sequence, and Tongue-based Airway Obstruction.

Background: Robin sequence (RS) describes a heterogeneous population with micrognathia, glossoptosis, and upper airway obstruction (UAO). Workup, treatment, outcomes assessment, and research inclusion are widely variable. Despite several classifications and algorithms, none is broadly endorsed. The objective of this investigation was to develop and trial a novel classification system designed to enhance clinical communication, treatment planning, prognostication, and research. Methods: This is a retrospective cross-sectional study. A classification system was developed with five elements: micrognathia, nutrition, airway, palate, syndrome/comorbidities (MicroNAPS). Definitions and a framework for "stage" assignment (R0-R4) were constructed. Stage "tongue-based airway obstruction" (TBAO) was defined for infants with glossoptosis and UAO without micrognathia. MicroNAPS was applied to 100 infants with at least 1-year follow-up. Clinical course, treatment, airway, and feeding characteristics were assessed. Descriptive and analytic statistics were calculated and a P value less than 0.05 was considered significant. Results: Of the 100 infants, 53 were male. Mean follow-up was 5.0 ±â€…3.6 years. R1 demonstrated feeding-predominant mild RS for which UAO was managed nonoperatively but gastrostomy tubes were prevalent. R2 was characterized by airway-predominant moderate RS, typically managed with mandibular distraction or tongue-lip adhesion, with few gastrostomy tubes and short lengths-of-stay. R3 denoted severe RS, with similar UAO treatment to R2, but with more surgical feeding tubes and longer admissions. R4 represented a complex phenotype with 33% tracheostomies, protracted hospitalizations, and delayed palatoplasty. R0 ("at risk") and TBAO groups displayed the most variability. Conclusions: MicroNAPS is easy to use and associated with relevant disease characteristics. We propose its adoption in clinical and research settings.