Bone grafting at the stage of mixed and permanent dentition in patients with clefts of the lip and primary palate

Secondary bone grafting of a residual alveolar cleft has become a well established procedure. However, little attention has been paid to the benefits of these bone grafts in patients with clefts of the lip and alveolus only. This retrospective and comparative study includes 21 patients who had received a secondary or a late secondary bone grafting procedure from tibia and whose mean clinical and radiographic follow-up after the bone graft was 5.5 years. Eighteen patients treated without bone grafting served as controls. Length and width of cleft, presence or absence of permanent lateral incisor, size of nasal floor bony defect, and interdental alveolar bony height in the cleft area were investigated. The results showed that bone grafting was indicated particularly in wide clefts with missing lateral incisors. Eruption of a tooth close to the cleft was facilitated and the bony support for teeth neighboring the cleft was improved. In some cases, additional support of the alar base of the nose was achieved and closure of an oronasal fistula facilitated. A further advantage of bone grafting of clefts of the primary palate was that it might make it possible to insert a titanium implant carrying an artificial tooth in the cleft area.     

Endosseous implants for prosthetic rehabilitation in bone grafted alveolar clefts

The authors report their experience in the surgical and prosthetic rehabilitation of three patients affected by sequelae of cleft lip and palate, with residual alveolar cleft and absence of maxillary anterior teeth. The patients were treated by means of late secondary bone grafting of the alveolar cleft, followed by the insertion of endosseous titanium plasma-sprayed implants (IMZ). After a further healing period (6-12 months) fixed dental prostheses were constructed. Preliminary results from this series have shown how dental prostheses supported by endosseous implants in grafted alveolar clefts are a very reliable possibility in dental rehabilitation of this malformation.     

Improved treatment of cleft lip and palate is now available

When cleft lip and palate treatment was introduced at Gothenburg in 1957, the procedure used was early bone grafting (EBG). By 1965, EBG had been omitted from the regimen, bone grafting being postponed until the appearance of mixed dentition. Analysis of the results of both techniques showed maxillary retrusion of different degrees. Accordingly, this routine was abandoned in 1975, being replaced by a procedure which is characterised by delayed closure of the hard palate (DCHP). Thus, the surgical procedure comprised the following steps: 1, lip closure at 1-2 months of age; 2, soft palate repair at 6-8 months; 3, final lip-nose surgery at 12 months; and 4, closure of the left in the hard palate, and bone grafting to the alveolar process during mixed dentition at about 8-10 years of age. Follow-up has shown the majority of patients to manifest acceptable speech development during childhood, though problems may occur in some cases. Maxillary growth has been found to be improved after DCHP, and at present the need of maxillary advancement surgery has been reduced to approximately 5% of cases, as compared with the former rates of 50% of cases among those treated with EBG, and of 25% among those treated with the vomer flap procedure.     

One-stage closure of uni- and bilateral cleft lip and palate

A preliminary report of an "all-in-one' one-staged closure of all forms of cleft lip and palate during the first year of life. The one-stage repair of complete uni- and bilateral clefts includes the anatomical reconstruction of soft palate, hard palate closure in two layers, alveoloplasty with bone grafting and lip repair. This surgical technique is described and early results presented.     

Bone grafting the piriform aperture deformity in isolated cleft lip patients: indication, technique, and results

PURPOSE: This study was undertaken to determine the effect of a bone graft in the piriform aperture on the nasal deformity and orthodontic treatment of the cleft side teeth in isolated cleft lip patients. PATIENTS AND METHODS: All primary cleft lip repair was done 3 months after birth. Nine patients, four female and five male, with a mean age of 12.5 years (range, 8.2 to 24.8 years) and with a repaired cleft lip, were bone grafted between 1992 and 1996. The mean postoperative period was 2 years (range, 1 to 4 years). An iliac crest bone graft was placed in the piriform aperture deformity on the side of the cleft lip. The improvement in the nasal symmetry and angulation of the cleft side teeth were evaluated. The eight growing cleft lip patients (mean age, 11 years; range, 9 to 13 years) were compared with a control group of eight healthy growing children (mean age, 11 years; range, 9 to 13 years). The improvement of nasal symmetry was measured by the formula of the lobule portion of the columella index preoperatively and postoperatively. RESULTS: The mean lobule portion of the columella index preoperatively was 41.8% (SD, 4.4%; SE of Mean, 1.5%) and postoperatively was 44.2% (SD, 4.9%; SE of Mean, 1.6%) (P > .006, t-test for paired samples). The angulation of the cleft side teeth was improved by orthodontic treatment. CONCLUSION: Bone grafting the piriform aperture deformity results in a stable result and improves nasal symmetry and the angulation of the cleft side teeth.     

Long-term assessment of early alveolar bone grafts using three-dimensional computer-assisted tomography: a pilot study

Fifteen patients with complete unilateral cleft lip and palate who had primary alveolar bone grafting were studied with computer-assisted tomography at a mean age of 12 years. Keeping the maxillary alveolar crest parallel to the plane of the scan, 1.5-mm cuts of the maxilla were made from the infraorbital rim to the gingival third of the crowns of the teeth. A single operator reformatted the data into three-dimensional images using the Maxiview 3200 computer workstation. This allowed examination of the position, size, and spatial relationship of the grafted area and quantification of the amount of bone coverage of root surface and bone height of the alveolus in or adjacent to the graft site. Ten patients showed a lateral incisor in the line of the cleft. The average bony coverage of these tooth roots was 76.5 percent. In the five patients in whom there was lateral incisor agenesis, the canine root had average bony coverage of 82.6 percent. The average height of bone at the lateral incisor was 8.7 mm; at the canine, 14.1 mm. In two patients in whom there was only 42 percent tooth root coverage, the teeth were still viable, stable, and without mobility. Computed tomographic (CT) scans of the 15 patients demonstrated good graft survival with adequate volume. The functional and aesthetic status of the dentition in the area of the cleft also was demonstrated.     

Oro-nasal fistula development and velopharyngeal insufficiency following primary cleft palate surgery—an audit of 148 children born between 1985 and 1997

We present an audit of primary cleft palate surgery in our unit including rates of two important post-operative complications.Multidisciplinary audit clinics ran from March 1998 to April 2002 to follow up all local patients with a cleft lip or palate who had undergone primary palatal surgery in our unit. One hundred and forty eight patients were studied. Patient ages at follow-up ranged from 3 years and 10 months to 17 years and 4 months. Two surgeons performed the primary surgery. One hundred and twenty eight Wardill-Kilner and 20 Von Langenbeck repairs were performed.We found a 4.7% rate of oro-nasal fistula development requiring surgical closure, and a 26.4% rate of velopharyngeal insufficiency (VPI) requiring subsequent pharyngoplasty. We noted that the type of cleft involved affected the rate of VPI, 16% of patients with unilateral cleft lip and palate versus 29.2% of patients with a solitary cleft palate requiring secondary surgery.Outcome of surgery was determined by a ‘Cleft Audit Protocol for Speech’ (CAPS) speech therapy assessment at follow-up clinics. Only 14.9% of all patients assessed demonstrated any degree of hypernasality.Our results compare favourably with other recent studies including the Clinical Standards Advisory Group (CSAG) report into treatment of children with cleft lip and palate.     

Excess mortality and its relation to hypertension and proteinuria in diabetic patients. The world health organization multinational study of vascular disease in diabetes

The speech problem in patients born with cleft lip and palate is mainly due to the insufficiency of the velopharyngeal (VP) valving mechanism, manifested as in visually seen nasal emission, and auditorily perceived hypernasality and articulation disorders. Evaluations of resonance and VP function can be conducted by: (1) perceptual rating scale based on speech pathologist's subjective judgement and (2) objective instrumental assessment, by the use of specific instrument. Nasopharyngoscopy has been commonly used clinically to diagnose VP function. The purpose of this study is: using nasopharyngoscopy to investigate the differences in VP mechanism between those with VP competence and VP incompetence in the dimension of velar displacement, lateral pharyngeal wall (LPW) displacement, degree of VP closure and pattern of VP closure. Ninty-eight subjects were studied from June 1990 to August 1991. They were divided into 4 groups: (1) group 1: normals with normal speech; (2) group 2: cleft of lip only, with normal speech; (3) group 3: cleft palate without nasal emission, but normal articulation; (4) group 4: cleft palate with nasal emission, with or without articulation error. Age range was from 6-47 years old with equal sex distribution. Ten Chinese sentences were used for standard test sentences, and were grouped according to Mandarin phonological distinctive features into 5 categories: (1) nasals; (2) vowels; (3) plosives; (4) fricatives/affricates; (5) connected number counting. The result indicates that the insufficient velar displacement to contact posterior pharyngeal wall is a determining factor causing velopharyngeal insufficiency in group 4; however, the lateral pharyngeal wall movement is not significantly different among 4 groups. Coronal pattern of velopharyngeal closure is the most common pattern among 4 groups of speakers.     

Current knowledge in cleft lip and palate treatment from an orthodontist's point of view

The aim of this review was to put new clinical research findings into proper perspectives relative to previously accepted knowledge on treatment of patients with cleft lip and palate. The first part of the paper deals with various aspects of infant orthopedic treatment, such as its influence on primary surgery, maxillary arch form and dimensions, feeding, psychological situation of the parents and speech development. Following parts analyze general maxillofacial growth outcome after surgery and also maxillofacial growth in relation to particular surgical procedures (palatal repair, periosteoplasty/gingivoplasty, bone grafting). The last part of the review discuss the effects of certain orthodontic/orthopedic treatment approaches as well as the role of dental implants in treatment of cleft lip and palate patients.     

Development of the residual cleft in the hard palate after velar repair in a 2-stage palatal repair regimen

Delayed closure of the hard palate is believed to improve maxillary growth and facial appearance in cleft lip and palate patients. However, the cleft opening in the hard palate after velar closure might impair speech development. The aim of this investigation was to study the development of the residual cleft in the hard palate after 2-stage palatal repair (TSPR) in children born with complete cleft lip and palate (bilateral [BCLP]; n = 7 or unilateral [UCLP]; n = 22) or isolated cleft palate (CP; n = 9). Moreover, we aimed to investigate whether any morphologic factors before surgery might predict development of the residual cleft. Dental casts obtained prior to velar repair (mean age 7 months) and postoperatively at 1 1/2, 3, 4, 5 and 7 years were analyzed with a Reflex Microscope regarding the width, length and area of the cleft in the hard palate. The palatal cleft varied in size both pre- and postoperatively in all 3 types of cleft patients. The width of the cleft in the UCLP subgroup showed a marked reduction immediately after velar repair, but then, on average, remained stable until final surgical closure of the hard palate. In the BCLP subgroup the initially rather narrow width of the clefts remained unchanged postoperatively. Clefts in the CP subgroup, especially in those with a complete cleft, remained large after veloplasty. In 4 of the UCLP and 2 of the BCLP patients, the cleft width increased gradually. In some other subjects, both in the UCLP and BCLP subgroups, the residual cleft closed functionally with time, but this development could not be foreseen.     

Evaluation of maxillary dental arch form in unilateral clefts of lip, alveolus, and palate from one month to four years

This study evaluated the early changes of maxillary alveolar arches of operated unilateral cleft lip and palate patients. Dental casts were available at four age increments. Triangular flap cheiloplasty was carried out at an early age. Two-stage palatoplasty by vomer flap and soft palate closure took place later. Prior to lip repair, the alveolar arches were classified according to the relationship between greater and lesser segments. Almost a quarter had overlap of the alveolar segments with no contact between the alveolar ridges at the cleft site; some had no overlap with contact of the alveolar segments in the cleft region; almost a quarter had both overlap of the alveolar segments and contact; and almost half had no overlap of the segments and the alveolar ridges were not in contact at the cleft site. After lip repair, the arch relationships were examined and the percentage of patients in each of the four groups indicated a moulding effect of lip repair on the alveolar segments. This moulding effect caused the alveolar segments in most patients to be in contact at the cleft site. Most of these also had segment overlap. All patients were re-examined shortly after palatal repair. The trend for segment overlap and contact continued after palate surgery. However, when all patients were seen at age 4, percentages of patients in each group indicated that previous overlap of segments improved to a more desirable nonoverlapped relationship in approximately half of the patients. The other half continued to demonstrate arch collapse, in excess of what would be considered ideal ridge relationship.     

Review: the Michigan cleft twin study

The combined effects of clefting of the lip and/or palate and of their surgical repair have been examined for a cross-sectional sample of 20 MZ and 25 DZ like-sexed twins discordant for clefting, in the age range of 4 to 17 years. The findings of four studies published since 1975 on that sample are explored for the primary, contiguous and pleiotropic effects of clefting. The primary effects on facial structures of repaired cleft lip appear to be minimal. However, for twins with repaired cleft of the palate (with or without cleft of the lip), the maxilla was both deficient antero-posteriorly and was positioned more posteriorly than in their non-cleft co-twins. The maxillary first molars were usually slightly less erupted in the cleft twins than in the non-cleft twins. The cleft palate only twins had larger cranial base angles than their non-cleft co-twins. A contiguous effect of the posteriorly positioned maxilla was a mandibular rotation downward and backward in the cleft palate and bilateral cleft lip and palate groups but not in the unilateral cleft lip and palate group. The slightly larger cranial base angles found for cleft palate only, although contiguous in location, are more likely pleiotropic effect. The pleiotropic effects include a deficit in height and weight for cleft subjects which appears only after puberty. Although the teeth of the cleft twins tended to be smaller than those of the non-cleft twins, the amount was not clinically significant.     

Long-term evaluation of the use of coralline hydroxyapatite in orthognathic surgery

PURPOSE: This prospective study was designed to evaluate the long-term clinical and radiographic results of porous block hydroxyapatite (PBHA) used as a synthetic bone graft in orthognathic surgery and craniofacial augmentation. PATIENTS AND MATERIALS: A total of 245 consecutive patients were treated initially. Inclusion criteria for this study included a minimum clinical and radiographic follow-up of 5 years. In addition, all patients with known implant failures were included regardless of whether they met the study criteria. There were 111 patients that met the criteria for inclusion in this study. All patients had undergone orthognathic surgery with rigid fixation and had had inlay or onlay PBHA implants placed. Ninety-six percent of the implants were placed through an intraoral approach. Long-term postoperative radiographs were visually compared with immediate postoperative radiographs for implant position, stability, resorption, and other significant radiographic changes. The clinical examination evaluated for signs and symptoms of infection, wound dehiscence, implant exposure, implant displacement, changes in the overlying mucosa, and development of oronasal or oroantral fistulae. RESULTS: Four hundred seventy-one implants were placed: 403 in the maxilla, 44 in the mandible, and 24 in the periorbital region. There were 289 implants placed in direct communication with the maxillary sinus. The average follow-up time was 7.2 years (range, 5.0 to 10.3 years). Twenty-three implants (4.9%) were removed during the evaluation period. Lateral maxillary wall grafting had 95.7% success, with nine implants being lost in three patients. One chin implant was removed because of dissatisfaction with the aesthetics. Seven (14%) midpalatal implants used for maxillary expansion were lost, primarily because of exposure of the implant to the oral or nasal cavity at the time of surgery. When PBHA was used for alveolar cleft grafting, there was a 100% failure rate. CONCLUSION: The use of PBHA as a bone graft substitute in orthognathic surgery and for facial augmentation showed a high percentage of success and efficacy. However, adequate soft tissue coverage in the nasal floor and on the palate are paramount for success of midpalatal implants. PBHA should not be used for alveolar cleft grafting. Rigid fixation for inlay implants in the maxilla is important to provide stress shielding of the material and minimize micromovement during the initial healing phase.     

Use of X-ray diffraction for studying the temperature dependence of the Young modulus of protein crystals

Conventionally, for dental reconstruction after bone grafting of the congenital residual alveolar cleft, a fixed prosthesis or removable partial denture is used. In this paper, residual alveolar cleft reconstruction with an osseointegrated implant following secondary bone grafting is described. The patient underwent secondary bone grafting of the residual alveolar cleft at the age of 18 years. One osseointegrated implant was placed in the bone bridge 8 months after bone grafting. No problems up to 1 year after the fabrication and placement of the fixed prosthesis have been observed.     

Primary gastrointestinal lymphoma--disease spectrum and management: a 15-year review from north India

The anthropometric measurements of face were taken in 21 infants of 6-9 months (15 boys, 6 girls) with bilateral cleft lip, alveolus and palate, prior to surgery. The control group consisted of 30 normal infants, without facial defects. In each child 9 measurements were performed. The comparative analysis revealed an underdevelopment of maxilla and mandible and an increase in nasal width in children with bilateral cleft lip and palate.     

Dynamic cleft maxillary orthopedics and periosteoplasty: benefit or detriment?

In 1990, Drs Millard and Latham published their initial experience with dynamic maxillary appliances (DMAs) and periosteoplasty for children with cleft lip and palate. The technique provided for alveolar alignment and consolidation, with elimination of oronasal fistulas. Opponents to this approach speculated about impairments to facial growth. To date no longitudinal studies have been published. Over the last 10 years, 35 unilateral and 10 bilateral complete clefts have been treated with this technique. All patients have been followed and documented clinically, orthodontically, and radiographically. Cephalometric analyses were performed on children after the age of 6 years. The children have excellent facial aesthetics with well-balanced lips and noses. Radiographs demonstrate bone within the repaired alveolar clefts. Articulated impressions show anterior and lateral crossbites in the unilateral patients that improve over time and appear to be correctable orthodontically. The bilateral patients have satisfactory occlusions and arch forms. Cephalometric analyses confirmed no evidence of skeletal crossbites or midfacial growth retardation. This is a work in progress that will continue as the children grow. Although definite and final conclusions would be premature, it can be stated that to date all patients are following consistent and favorable growth patterns. Our team is confident in proceeding with this technique.     

Effects of ultraviolet irradiation of blood on the immunity indices in patients with suppurative diseases of soft tissues

Primary gingivoperiosteoplasty according to Millard consists of active presurgical orthopedic treatment with the Latham device at the age of 4 months and surgical covering of the alveolar cleft by local mucoperiosteum flaps at the age of 6 months. The aim of this investigation was to evaluate the facial growth following use of the Latham device. Lateral head X-rays and plaster casts from 146 patients with unilateral and bilateral clefts of lip and palate were investigated (follow-up of 16 years). Ninety-one of these patients formed the control group and received no Latham device and no gingivoperiosteoplasty. The same surgeon and orthodontist treated all of the 146 patients. Three-dimensional growth disturbance was observed after application of the Latham device and gingivoperiosteoplasty. Forty-two percent of patients with UCLP and 40% patients with BCLP had an "open bite" following closure of the alveolar cleft (control group 5%-10%): the length of the upper jaw was shorter than in the control group and the frequency of cross-bite was higher. These results demonstrate that treatment with a Latham device followed by gingivoperiosteoplasty disturbs facial growth. Therefore this treatment should be rejected.     

Reconstruction of residual alveolar cleft defects with one-stage mandibular bone grafts and osseointegrated implants

PURPOSE: This study evaluates a treatment regimen for reconstruction of residual maxillary alveolar cleft defects consisting of mandibular bone grafting and immediate implant installation. PATIENTS AND METHODS: Sixteen cleft patients (five female and 11 male) had residual cleft defects of the alveolar ridge reconstructed with bone grafts from the mandibular symphyseal region. The bone graft was pretapped at the donor site before fixation in the residual ridge with Br?nemark implants. Twenty implants were installed according to this concept. The period of observation ranged from 36 to 69 months, with a mean of 48 months after implant installation. RESULTS: Five patients developed wound dehiscenses that resulted in total or partial bone graft sequestration. Two implants were lost, one due to sequestration and the other due to mobility at the abutment procedure; 18 implants were still well functioning at the end of the observation period. However, all patients showed significant periimplant bone resorption after this one-stage treatment. CONCLUSION: Because of the observed complication rate, the one-stage procedure may not be optimal for reconstructing residual cleft defects.     

Axial ultrasonographic imaging of the fetal maxilla for accurate characterization of facial clefts

The purpose of this study was to determine whether scanning of the fetal midface in the axial plane allows accurate characterization of facial clefts. During fetal anatomic survey, facial clefts were identified in six fetuses. The midface anatomy was evaluated with ultrasonography in the coronal and axial planes, and the clefts were characterized prospectively as unilateral or bilateral and as involving the lip alone or both the lip and the palate. The integrity of the upper lip was assessed in the coronal and axial planes. The continuity of the normal C-shaped curve of the tooth-bearing alveolar ridge and the anterior six tooth sockets was assessed in the axial plane. The prospective prenatal diagnosis was correlated with postnatal findings in all cases. The clefts where characterized prospectively as unilateral cleft lip (one case), unilateral cleft lip and cleft palate (four cases), and bilateral cleft lip and cleft palate (one case). The prenatal characterization was confirmed to be correct postnatally in all cases. Prenatal sonographic evaluation of the axial view of the tooth-bearing alveolar ridge of the maxilla allows accurate determination of whether a cleft is confined to the lip or involves both the lip and the palate.     

Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair

We present a new combined approach to primary bilateral cleft lip, nose, and alveolus repair using presurgical nasoalveolar molding combined with a one-stage lip, nose, and alveolus repair. Presurgical alveolar molding is used to bring the protruding premaxilla back into proper alignment with the lateral segments in the maxillary arch. Presurgical nasal molding produces tissue expansion of the short columella and nasal lining. A coordinated surgical approach involves a one-stage repair of the lip, nose, and alveolus. The nasal repair uses a retrograde approach in which the prolabial flap and columella are reflected over the nasal dorsum by continuing the dissection behind the prolabium up the membranous septum and over the septal angle. Tissues are dissected out from between the tip cartilages, and the domes are sutured together in the midline. This method joins a new class of bilateral cleft repairs that place the primary emphasis on correction of the deformity of the nasal tip cartilages.