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.     

Secondary alveolar bone grafting--five-year periodontal and radiographic evaluation in 100 consecutive cases

A prospective study of secondary alveolar bone grafting based on the Norwegian (Oslo) team approach has been conducted by the CLP Unit at the Princess Margaret Hospital for Children in Perth, Australia, since 1982. The 5-year results of 100 consecutive cases of uni- and bilateral cases are presented according to periodontal and radiographic parameters of tooth support. The vast majority of cases grafted (98%) resulted in the eventual eruption of the cleft side cuspid/lateral incisor within acceptable parameters of tooth support. The results confirm the predictability of this safe procedure when utilized within a strict clinical protocol involving the whole CLP team.     

Alveolar bone grafting in unilateral complete cleft lip and palate patients

Autogenous bone graft of an alveolar cleft area has the following advantages: (1) assistance in the closure of buccoalveolar oronasal fistula; (2) provision of bony support for unerupted teeth and teeth adjacent to the cleft; (3) formation of a continuous alveolar ridge to facilitate orthodontic correction of malocclusion; (4) supporting the nostril floor and alar base to improve nasal aesthetics. It has been well accepted in most craniofacial centers as routine procedure in cleft lip and palate rehabilitation. A new surgical technique for alveolar bone grafting has been introduced to the Chang Gung Craniofacial Center since July 1991. It provided a good exposure of the alveolar cleft, primary closure of the fistula and adequate volume of bone graft. A review of 27 consecutive alveolar bone grafting procedures performed in unilateral cleft lip and palate patients from July 1991 to June 1992 was presented. Patients have been followed up for at least 6 months. The alveolar bone graft was evaluated clinically and radiologically at one week, six months and one year after the surgery. The preliminary results indicated that the new surgical technique produced less chance of recurrent fistula, good postoperative gingival height, and improvement of nasal aesthetics. Based on the results of this new study we strongly advocate the use of this new surgical technique.     

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.     

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.     

Maturation alters the contractile role of calcium in ovine basilar arteries

OBJECTIVE: To investigate the distribution patterns of primary and permanent teeth in the cleft area and the numerical variation in teeth in unilateral complete cleft lip and palate (UCLP) patients. DESIGN: A survey of the dentition in UCLP patients. SETTING: Craniofacial Center, Chang Gung Memorial Hospital, Taipei, Taiwan. PATIENTS: 137 UCLP patients who met the following criteria: (1) have had at least one panoramic film taken, (2) the first panoramic film illustrates either primary or early mixed dentition. Evaluation of both permanent and primary dentition was available in 91 cases. MAIN OUTCOME MEASURES: Two evaluators performed independent evaluations of number and distribution of teeth in UCLP patients. The hypothesis that there are two odontogenic origins for maxillary lateral incisors was proposed to explain the occurrence of distribution patterns of dentition in the cleft area and to explain differences between primary and permanent dentition in UCLP patients. RESULTS: Four distribution patterns in the cleft area were identified in both the primary and the permanent dentition. In the primary dentition, placement of the lateral incisor distal to the alveolar cleft was the predominant pattern (pattern y, 82.4%), followed by absence of the cleft side maxillary lateral incisor (pattern ab, 9.9%), presence of one tooth on each side of the alveolar cleft (pattern xy, 5.5%), and placement of the lateral incisor mesial to the alveolar cleft (pattern x, 2.2%). In the permanent dentition, the most common pattern was the absence of the maxillary lateral incisor on the cleft side (pattern AB, 51.8%), followed by lateral incisor placement distal to the alveolar cleft (pattern Y, 46%), lateral incisor placement mesial to the alveolar cleft (pattern X, 1.5%) and the presence of one tooth on each side of the alveolar cleft (pattern XY, 0.7%). The discrepancy between the distribution patterns of primary dentition and permanent dentition successors is 57.1%. Variations in tooth number in both primary and permanent dentition of UCLP patients occurred most often in the cleft area. Abnormalities in the number of teeth (hypodontia or hyperdontia) outside the cleft area were more common in the permanent dentition than in the primary dentition (24.1% versus 4.4%). CONCLUSIONS: Four distribution patterns in the cleft area were identified in both sets of dentition. Our findings of distribution patterns in UCLP patients support the hypothesis that there may be two odontogenic origins for maxillary lateral incisors. Clinicians involved in managing the dentition of UCLP patients should consider the high frequency of numerical variation both in and outside the cleft area before starting dental treatment.     

Abnormalities of the maxillary incisors in children with cleft lip and palate

Dental anomalies of the maxillary anterior teeth were studied in seventy-seven children affected by unilateral and bilateral clefts of the lip and alveolar process, with or without involvement of the palate. As for the permanent lateral incisor in the cleft area, our results show that its congenital absence is the most frequent abnormality followed by anomalies in size and shape and supernumerary teeth. Enamel hypoplasia was found to affect the permanent central incisor on the cleft side more frequently. Early recognition of tooth abnormalities during the primary dentition phase for an interceptive treatment of potentially severe problems was emphasized.     

Minimally invasive iliac cancellous bone graft harvesting

We have described a technique for harvesting cancellous bone from the ilium that is minimally invasive and safe. This technique results in minimal donor-site morbidity, is quick and easy to perform without the need for special equipment or instruments, and allows a two-team operative approach. Sufficient bone graft material can be obtained for wide or bilateral clefts. We now use this technique routinely to harvest cancellous bone for secondary alveolar bone grafting in children with clefts. The procedure could be used in adults, it could also be used to obtain bone graft for treating other conditions, and other donor sites could be approached with the same technique.     

Surgical treatment of unilateral alveolar cleft

In this study, 16 cases of unilateral alveolar cleft with cleft lip and palate were repaired with autografts of cancellous bone (13 cases) or hydroxyapatite (3 cases). The grafts were covered by reflected mucoperiosteal flaps and a mucosal flap from the upper lip. Twelve of the thirteen cases were followed up for 1-5 years. Nine of whom using cancellous bone had bony continuity of the maxilla and 7 cases erupted permanent maxillary canines within the area of autografts. None of the 3 cases using hydroxyapatite erupted a canine tooth. The results showed that autograft was better than hydroxyapatite in terms of maxillary canine eruption.     

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.     

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.     

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.     

Msx1 deficient mice exhibit cleft palate and abnormalities of craniofacial and tooth development

The Msx1 homeobox gene is expressed at diverse sites of epithelial-mesenchymal interaction during vertebrate embryogenesis, and has been implicated in signalling processes between tissue layers. To determine the phenotypic consequences of its deficiency, we prepared mice lacking Msx1 function. All Msx1- homozygotes manifest a cleft secondary palate, a deficiency of alveolar mandible and maxilla and a failure of tooth development. These mice also exhibit abnormalities of the nasal, frontal and parietal bones, and of the malleus in the middle ear. Msx1 thus has a critical role in mediating epithelial-mesenchymal interactions during craniofacial bone and tooth development. The Msx1-/Msx1- phenotype is similar to human cleft palate, and provides a genetic model for cleft palate and oligodontia in which the defective gene is known.     

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.     

Prospective evaluation of morbidity associated with iliac crest harvest for alveolar cleft grafting

PURPOSE: This study prospectively evaluated the morbidity associated with iliac crest bone harvest when performed for alveolar cleft grafting. PATIENTS AND METHODS: Twenty-two consecutive patients who underwent an alveolar cleft graft with iliac crest bone harvest were evaluated. The estimated blood loss, length of hip incision, and volume of bone that was harvested were recorded. The duration of time until postoperative ambulation and the length of hospitalization were measured. RESULTS: All patients tolerated the iliac harvest without major complication, and the volume of bone was sufficient in all but one case. Postoperatively, ambulation occurred at an average of 3 hours 18 minutes. Twenty-one patients were discharged the day after surgery; one patient had the surgery performed as an outpatient. CONCLUSIONS: Harvesting cancellous bone from the iliac crest does not result in delayed ambulation or prolonged hospitalization. The morbidity that has been reported to occur with iliac crest bone harvest was not consistent with the results of this study.     

Lumbar percutaneous endoscopic interbody fusion

Since 1982, percutaneous endoscopic control has been found to be a fundamental help for selective posterior subligamentary decompression in lumbar contained disc herniations. After the first clinical experience in 1986 with percutaneous intervertebral bone grafting, the need for sufficient percutaneous preparation of the adjacent vertebral plates and postoperative immobilization of the operated on segment became evident. So in 1988, the original eccentrically abrasive end plate cutter for application under discoscopy was introduced. For a preoperative trial and postoperative stabilization, the complementary use of the external pedicle fixation device was standardized in 1988. The use of percutaneous autologous bone interposition was found essential for optimal bony interbody consolidation. The indications were limited strictly to monosegmental lumbar dysfunctions without a need for peridural decompression. In a series of 37 patients with standardized procedure and a mean followup of 33 months, bony interbody consolidation was achieved in 30 cases. The technique desists from any need for blood transfusion, and functional rehabilitation is facilitated because of the very limited percutaneous approach.     

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.     

The effect of substance P upon middle ear effusion of secretory otitis media and the mode of action

BACKGROUND: The lumbosacral lucent cleft was first described in association with traumatic injuries to the neck. However, we have observed this sign to be present in patients with no precursor of trauma, and we reviewed the incidence of lucent cleft sign in our local population and any characteristic features of the lucent cleft. METHODS: Four-hundred and thirty lumbosacral spine radiographs were examined prospectively over an 8-month period, with correlation with clinical findings. Follow-up radiographs were obtained at 1, 3 and 6 months for patients with the lucent cleft sign. FINDINGS: Nineteen patients (4.4%) were found to have lucent clefts in their lumbosacral spine X-rays. No significant change in the number and features to the lucent clefts was noted even when the symptoms had resolved after 6 months. All the lucent clefts were linear, horizontally oriented and located at the anterior edge of the adjacent vertebral body. CONCLUSION: The lucent cleft sign in the spine, which has so far been described in association with has spinal trauma may be completely innocuous in patients with little or no symptoms.     

Maxillary distraction: aesthetic and functional benefits in cleft lip-palate and prognathic patients during mixed dentition

In the last few years, distraction techniques have been used successfully to correct the hypoplastic human mandible. In patients with cleft lip and palate, normal growth of the maxilla may be impaired by early cleft repair, and many of them do not respond to orthodontic procedures alone. Maxillary distraction is an alternative technique to correct maxillary hypoplasia during mixed dentition. In the last 3 years, the procedure was performed in 38 patients aged between 6 and 12 years; 18 patients had unilateral cleft lip and palate, 9 patients had bilateral cleft lip and palate, 7 patients had unilateral cleft palate, 2 patients had prognathism, and 2 patients had nasomaxillary dysplasia. Photographs, posteroanterior and lateral cephalograms, and dental models are obtained preoperatively (as well as an orthopantomogram) to locate the tooth buds. A subperiosteal dissection is performed exposing the anterior and lateral aspects of the maxilla, and an incomplete horizontal osteotomy is done above the tooth buds. Using a facial mask and an intraoral fixed appliance system as an anchorage, we initiate on the fifth postoperative day the application of distraction forces. Maxillary advancement between 4 and 12 mm is achieved during 3 to 4 weeks, and a satisfactory class I or II molar relationship is also obtained. A combination of forward and downward distraction forces can be used to achieve simultaneous advancement and elongation of the hypoplasic maxilla. The aesthetic results are excellent, and the nasolabial angle is increased, including a more anterior projection of the upper lip. Nasal breathing is improved as well as the air flow and patency of the nasal airway. Velopharyngeal function remains unchanged after the procedure. The follow-up in this series varied from 6 months to 3 years. No relapses have been observed.     

Vertebral pseudarthrosis in the osteoporotic spine

STUDY DESIGN: Radiologic and operative findings of intravertebral cleft in the osteoporotic spine were investigated and the pathomechanism discussed. OBJECTIVES: To clarify the pathologic features of the intravertebral cleft. SUMMARY OF BACKGROUND DATA: Intravertebral "vacuum" cleft is one of the common radiographic findings in the osteoporotic spine. It is thought that the cleft is a rare lesion of an ununited fracture, or pseudarthrosis. Evidential findings of the disease, however, have never been reported. METHODS: Simple bone grafting was performed in five cases (average age, 76.8 years) of thoracolumbar intravertebral cleft in osteoporotic spine in patients who had been suffering from prolonged pain of the back or leg. Preoperative radiologic evaluation using flexion-extension radiograph and magnetic resonance imaging was performed in all patients. At operation, the cleft and the components of the structure were macroscopically and microscopically observed. The fluid content in the cleft was biochemically analyzed. RESULTS: In all patients, preoperative flexion-extension radiographs showed intravertebral instability at the location of the clefts that indicated gas density in three cases and water density in two cases. Magnetic resonance imaging showed that, for the most part, the cleft was low intensity on the T1-weighted image and high intensity on the T2-weighted scans, regardless of the radiographic findings. At operation, abnormal movement was observed at the cleft of the affected body, which was covered with hypertrophic membrane. The serous fluid within the cleft was aspirated before the excision of soft tissue. The thick membrane was excised and showed that the cleft was lined by smooth fibrocartilaginous tissue and the great degree of motion between the fracture ends that is consistent with the pathologic appearance of pseudarthrosis. CONCLUSIONS: The unstable cleft in the affected vertebral body of the osteoporotic spine with magnetic resonance findings of low intensity on the T1-weighted scans and high intensity on the T2-weighted scans suggests that the cleft is a false joint lined by fibrocartilaginous tissue with notable movement consistent with pseudarthrosis.