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Dr.Muhammad Asim
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Primary bone grafting: Done at the time of primary lip repair
Discontinued now because of negative effect on midface growth.
Reduced anteroposterior maxillary development Reduced vertical growth of the anterior maxilla.
Increased incidence of crossbites
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Secondary Bone grafting
Done after palatal closure
Early secondary bone grafting (2 to 5 years)
Intermediate or secondary bone grafting (6 to 15 years)
Late secondary bone grafting (adolescence to adulthood).
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Unified maxillary reconstruction and continuous alveolar formation.
Physiologic eruption of the teeth adjacent to the cleft.
Stabilization of cleft fragments
Opportunity for a rapid expansion of the midline suture.
Elimination of oro-nasal fistulas
Overall facial esthetic improvements
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However, all surgical and grafting procedures can cause
growth alterations with bone dysplasias that are more
severe when the procedure is performed early.
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Many factors are involved in the success of alveolar bone grafting.
Canine position and its eruption stage at the time of bone grafting.
The success of bone grafts decreases if the procedure is performed
after canine eruption on the cleft side.
The Role of the therapy protocol and the orthodontic role, which
have not been explored in the literature.
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The aims of this study were
To evaluate the long-term stability of bone grafts with
an orthodontic-surgical protocol
To determine the success rate of bone grafts in minor
vs severe clefts, and
To develop a qualitative method for assessing the
success of bone grafting.
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Retrospective clinical trial
Authors analyzed the records of 446 complete cleft lip and palate
patients of the regional hospital.
Inclusion criteria
Congenital complete cleft lip and palate.
Treatment with the protocol of the regional hospital of vicenza and
the university of ferrara.
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Digital occlusal radiographs before (T0), immediately after (T1), and
at least 1 year after bone grafting (T2)
Performance of the alveolar bone graft by the same surgeon
Digital occlusal x-rays exposed with a standardized radiologic
technique (long-cone technique and root direction perpendicular to
the palatine midline)
Standardized radiographic evaluations
Informed consent from each patient.
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At birth: placement of a passive palate plate.
At 3 months of age: soft-palate surgery and lip and nostril surgery
with definitive lip repair.
At 6 months of age: unilateral and bilateral rhinoplasty.
At 8 to 12 months of age: initiation of speech therapy.
At 18 to 20 months of age: hard palate surgery and continuation of
speech therapy
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At 5 years of age: RPE + Facemask therapy.
At 6 to 9 years of age: placement of a passive transpalatal bar.
At 9 to 11 years of age: ABG
At 9 to 15 years of age: orthodontic fixed therapy
At 18 years of age: plastic (lip revision, nose revision, rhinoplasty,
nasal septum surgery, adenoid surgery, sinus mucous membrane
surgery, scar surgery) or maxillofacial surgery and implantation ifnecessary.
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Based on the results, the patients were divided into the following
groups:
Minor cleft: type I, score 1 or 0.5, on both teeth adjacent to the cleft.
Moderate cleft: types II and III, score 0.5, on both teeth adjacent to
the cleft.
Severe cleft: type IV, score 0, on both teeth adjacent to the cleft.
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Successful outcome at T2 was defined as:
Vertical and horizontal bone values equal to or better than the
bone values at T1
Type I and score 1 (vertical and horizontal bone levels
approximately normal), with bone support greater at T2 than at T0
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Nonparametric chi square test: To correlate the severity of the
defect to the success of bone grafting at T2.
Kendall coefficient of concordance: To compare Bergland scale with
the Witherow-derived scale.
Linear regression analysis: Toanalyze the potential effects of sex
and age (at bone grafting).
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The patients were divided into those who were 10 years or younger
and those older than 10 years, in accordance with sample medians
equal to 10 years old.
Binomial test: To assess the effects of type of cleft (unilateral or
bilateral) and lateral incisor agenesis.
Wilcoxon signed rank test: To determine the surgical success rates
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The success rate at T1 was 70.41% (95% CI). The success rate at
T2 was 91.84% (95% CI).
The correlation between cleft palate severity and success rate at T2was not statistically significant (P=0.64).
The Kendall coefficient of concordance was 0.99 for both the
Bergland and the Witherow-derived scales, indicating that these
scales were comparable.
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There was no statistically significant correlation between the
patient's sex or age and the success of the alveolar bone graft at T2
(P=0.08 and=0.94, respectively).
There was no statistically significant influence of the type of cleft
(unilateral or bilateral) and lateral incisor agenesis on the long-term
stability of the bone graft (P=0.84 and 0.32 ).
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At T1 and T2, there was no statistically significant difference
between Bergland bone levels at sites 1 and 2 (P=0.47).
Spontaneous canine eruption at T2 was not associated with lateral
incisor agenesis (P=0.34) or cleft palate severity at T0 (P=0.77).
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Teeth lost adjacent to the cleft at T2 did not correlate with cleft
palate severity (P=0.64) or type of cleft at T0 (P=1).
There were 12 patients (24.48%) with diminutive teeth outside the
cleft area.
None had supernumerary teeth far from the cleft side.
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Success rates were 70.41% (95% CI) at T1 and 91.84% (95% CI) at
T2.
These correspond well with results reported in the literature.
Bergland et al in 378 patients; 90%
Amanat and Langdon in 34 patients; 83%
Long et al in 43 patients; 91%
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In this study, the average age at bone grafting was 10.25 years, with
a range of 8 to 14.7 years. This is similar to the data reported by
Paulin et al, McWilliam and Long et al.
In this study, Cleft severitywas not statistically correlated with the
rate of surgical success at T2. Therefore, minor, moderate, and
severe clefts appear to have the same long-term stability.
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At T0, there was a statistically significant difference in the Bergland
Bone levels between site 1 (mesial side of the cleft) and site 2
(distal side of the cleft). In this study, site 2 had a higher bone level
than site 1.
This is consistent with the findings of Teja et al and Long et al.
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Both authors suggested that, unlike the apex of the distal tooth, the
apex of the mesial tooth was not always covered by bone. In this
situation, the clinician should not use orthodontic force to prevent
root resorption.
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At T1 and T2, there were no statistically significant differences
between the Bergland bone levels at sites 1 and 2. These data
correlated with good stability of the bone grafts.
At T2, 38 of the 49 patients (77.55%) had spontaneous canine
eruption through the grafted bone. The success rate in this
sample is comparable with the average percentage reported in
the literature (75%).
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Following factors are involved in spontaneous canine eruption in
cleft patients:
Arch developmentwith previous orthopedic expansion.
Creation of space for canine eruption with orthodontic therapy.
Periodontal health of the canine with respect to the root during the
graft surgery.
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In addition, the grafted bone itself plays a basic role by triggering a
cytokine cascade through interactions between the bone and the
canine follicle. The molecular basis of this phenomenon is unknown.
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Patients with alveolar clefts have a 20-fold increased risk forCanine
impaction (18.9%) compared with the general population (1-2%)
However, Canine impaction do not affect the bone height after the
bone graft.
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In this study, 65.31% (95% CI) of the patients had lateral incisor
agenesis.
The high rate of dental anomalies on the cleft side might be due to a
deficient blood supplyorectodermal and mesodermal tissues during
embryogenesis.
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Spontaneous canine eruption at T2 was not significantlyassociated
with lateral incisor agenesis.
Spontaneous canine eruption at T2 was not significantlyassociated
with cleft severity at T0.
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In patients with bilateral clefts, there was only 1 with a normal
canine pattern of eruption at T2.
The presence of deciduous teeth, lateral incisor guidance, and
interactions between cytokine and bone are all well-characterized
factors that influence canine eruption, which is usually absent or
more compromised in bilateral than in unilateral cleft patients.
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Only 3 patients (6.12%) had lost teeth adjacent to the cleft side at
T2. Two patients had peg-shaped lateral incisors, and 1 patient had
microdontic supernumerary teeth instead of a lateral incisor; these
were extracted during the graft surgery.
This finding concurs with the findings of Long et al, Tooth loss
adjacent to the cleft at T2 did not correlate with cleft severity or type
of cleft at T0.
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There was no significant correlation between age or sex and the
long-term stability of the bone graft.
There was also no significant association between cleft severity
(minor, moderate, severe) at T0 and the success of the alveolar
graft at T2, or between the type of cleft (unilateral or bilateral) and
the stability of the alveolar graft.
There is no significant correlation between lateral incisor agenesis
on the cleft side and the long-term success of bone grafts.
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Pre-graft orthodontic treatments yield better access for the surgeon
Post-graft orthodontic procedures can correct the positions of the
permanent teeth in the grafted area, which also have a functional
role in the stability of the bone graft.
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Orthopedic maxillary protraction and expansion should be done
before graft surgery.
If expansion is carried out after bone grafting, fistulae can appear,
leading to an additional surgical procedure.
The palatal expansion increases the transverse maxillary dimension
and the sagittal projection of the nasal spine and improves the
growth prognosis and the percentage of spontaneous canine
eruptions.
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Tooth eruption in the grafted bone contributes to its long-term
stability.
The grafted side must be restored with functioning prosthetic teeth
(implants) as soon as possible to prevent bone loss.
The long-term stability of dental implants in the cleft side ranges
from 82.2%64 to 98.6%.
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The success rate of bone grafts at T2 was 91.84, suggesting a high
percentage of success with this therapy protocol.
Cleft severity was not statistically correlated with success at T2,
demonstrating the protocols efficacy and its ability to repair clefts of
varying severity.
The concordance rate between the Bergland and the Witherow-
derived scales was 87.07% , indicating that this is a simple andreliable 2-dimensional method for assessing the success of bone
grafts as a useful clinical and experimental tool.
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