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PubMed1998

Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperiosteoplasty.

OBJECTIVE: The purpose of this study was to evaluate if narrowing and approximation of the alveolar cleft through presurgical alveolar molding followed by gingivoperiosteoplasty (GPP) at the time of lip repair reduces the need for a bone-grafting procedure. DESIGN: This was a retrospective blind study of patients with unilateral or bilateral alveolar clefts who underwent presurgical infant alveolar molding and GPP by a single surgeon. Alveolar bone formation was assessed prior to the eruption of the maxillary lateral incisor or canine by clinical examination, panoramic and periapical radiographs, and/or a dental CT scan. The criterion for bone grafting was inadequate bone stock to permit the eruption and maintenance of the permanent dentition. SETTING: This study was performed at the Institute of Reconstructive Plastic Surgery by the members of the Cleft Palate Team. PATIENTS: All patients with unilateral (n = 16) or bilateral (n = 2) alveolar clefts who underwent presurgical infant alveolar molding and GPP by a single surgeon from 1985 to 1988 were studied. The control population consisted of all alveolar cleft patients (n = 14) who did not undergo alveolar modeling or GPP during the same time period. INTERVENTIONS: Presurgical alveolar modeling was performed with an intraoral acrylic molding plate. This plate was modified on a weekly basis to align the alveolar segments and close the alveolar gap. The surgical intervention consisted of a modified Millard GPP. MAIN OUTCOME MEASURES: The primary study outcome measure was the elimination of the need for a secondary bone graft in patients who underwent presurgical alveolar molding and GPP. RESULTS: Of the 20 sites in the 18 patients who underwent GPP, 12 sites did not require an alveolar bone graft. Of the 8 sites requiring a bone graft, 4 presented minimal bony defects. All 14 patients in the control group required bone grafts. CONCLUSIONS: In this series of 20 alveolar cleft sites treated with presurgical orthopedics and GPP, 60% did not need a secondary alveolar bone graft in the mixed dentition.

Alveolar Process↗
PubMed1998

Changes in craniofacial development due to modifications of the treatment of unilateral cleft lip and palate.

OBJECTIVE: The objective of this study was to evaluate the craniofacial morphology of children with unilateral cleft lip and palate (UCLP) resulting from differing management protocols practiced in Prague from 1945 to 1976. DESIGN: The craniofacial morphologies of four groups of patients were compared. Two groups were assessed retrospectively (individuals born from 1945 to 1963), and two groups were followed on a longitudinal basis (individuals born from 1966 to 1976). SETTING: The study was conducted at the Cleft Lip and Palate Center at the Department of Plastic Surgery, Prague, which has a catchment area population of 6 million. PATIENTS: The subjects were a consecutive series of adult males (n = 84) who had complete UCLP without associated malformations. INTERVENTIONS: Patients born from 1945 to 1955 did not receive centralized orthodontic therapy. From 1945 to 1965, the alveolar process in the area of the cleft was not surgically repaired. Primary bone grafting was used for the group born from 1965 to 1972, and primary periosteoplasty was used in the subsequent period. Throughout the period covered by the study, the palate was operated on by pushback and pharyngeal flap surgery. From 1945 to 1965, the lip was repaired initially according to Veau, and later according to Tennison and Randall, and during this time, fixed appliances were used for orthodontic treatment. RESULTS: The results for the period from 1945 to 1955 are characterized by mandibular overclosure with anterior crossbite. Centralized orthodontic treatment in the later period improved sagittal jaw relations due to the posterior displacement of the mandible and an edge-to-edge bite was attained, but maxillary retrusion was unchanged. Primary bone grafting increased retrusion of the maxilla, which was compensated by further posterior displacement of the mandible. An edge-to-edge bite was also obtained. Primary periosteoplasty reduced maxillary retrusion, and the marked proclination of the upper dentoalveolar component with fixed appliances resulted in a positive overjet. It was no longer necessary to push the mandible back to the extent required in bone grafting. CONCLUSION: Effective orthodontic treatment made the greatest contribution to improved facial development. It allowed compensation of maxillary retrusion by changes in the position of the mandible or by proclination of the upper dentoalveolar component with fixed appliances. The applied surgical methods using primary bone grafting caused deterioration of the anterior growth of the maxilla.

Adult↗
PubMed1998

Surgical repositioning of the premaxilla in combination with two-stage alveolar bone grafting in bilateral cleft lip and palate.

OBJECTIVE: This paper introduces a surgical technique for premaxillary repositioning in combination with two-stage alveolar bone grafting for the correction of the premaxillary deformity of patients with bilateral cleft lip and palate (BCLP). The paper also reports on two patients with BCLP who underwent this surgical management. SURGICAL PROCEDURE: The operation is usually performed when the patient is 8 to 14 years of age. In the first stage of surgery, the side more accessible to the septo-premaxillary junction is selected, and an osteotomy of the premaxilla and unilateral alveolar bone grafting are performed. Approximately 4 to 12 months after the first stage of surgery, contralateral alveolar bone grafting is carried out. CONCLUSION: We have found that this surgical procedure is highly effective, because it ensures the blood supply to the premaxilla and minimizes the potential for surgical failure. Moreover, it affords wide exposure of the premaxillary bone surface, facilitating sufficient boney bridging and allowing for orthodontic tooth movement.

Adolescent↗
PubMed1998

Maxillary dental development in complete unilateral alveolar clefts.

OBJECTIVE: This study was conducted to determine whether development of individual maxillary teeth in subjects with complete unilateral alveolar clefts was significantly different from that found in unaffected children. DESIGN: Retrospective, mixed longitudinal. SETTING: Craniofacial Center, university based. MATERIALS AND METHODS: A sample of 179 panoramic radiographs obtained during the mixed dentition from 79 subjects (47 males, 32 females) with complete alveolar clefts was analyzed. After visual evaluation of root development of the permanent maxillary teeth from radiographs, a score from 0 to 5 was assigned utilizing a predefined scoring system. Statistical analyses were performed between the cleft and unaffected reference groups available in the literature. RESULTS: The cleft side dentition was found to be significantly delayed in development relative to the noncleft side (p < .05). Compared to the reference group, the cleft side lateral incisor demonstrated a mean difference in development of 1.59 years followed by the canine (1.39 years), the central incisor (0.96 years), the first premolar (0.94), and the second premolar (0.78). CONCLUSION: Teeth directly adjacent to the cleft site were shown to be the most delayed. The lateral incisors and canines were observed to be the most variable when compared to their corresponding antimeres. The information obtained from this study may assist the orthodontist in selecting the appropriate time to initiate orthodontic treatment in order to prepare the permanent dentition prior to alveolar bone grafting.

Adolescent↗
PubMed1998

A comparison of two different bone-harvesting techniques for secondary alveolar bone grafting in patients with cleft lip and palate.

OBJECTIVE: To compare the outcome of the trephine with open hip surgery for alveolar bone grafting in cleft lip and palate surgery. DESIGN: The study was retrospective. The radiographs were assessed blindly and on two separate occasions 1 week apart. SETTING: University Teaching Hospital. PATIENTS, PARTICIPANTS: In one group (group A), a trephine was used; in the other (group B), open hip surgery was employed. Group A was comprised of 16 patients (nine with unilateral and seven with bilateral clefts of the lip and palate) and group B, 13 patients (eight unilateral and five bilateral). The prime entry criterion for inclusion in the study was that the canine tooth had erupted into the graft site. INTERVENTIONS: A long cone periapical radiograph was taken of the erupted canine tooth in the graft site. MAIN OUTCOME MEASURE: The radiographs were graded from type I to type IV, as described by Bergland et al. (1986a). A comparison was also made of the eruption of the canine, postoperative morbidity, and length of stay in hospital for each group. RESULTS: There was no statistically significant difference in the interdental bone height (p=.61, Mann-Whitney U test). In group A, all patients had a satisfactory clinical outcome (type I or II), and in group B, only one patient had an unsatisfactory result (type III). The spontaneous eruption of the canine and the number of nights spent in the hospital were also similar for both groups. However, no patients in group A suffered postoperative complications, whereas three patients in group B reported either a limp or postoperative infection of the hip. CONCLUSION: Both techniques produced satisfactory repair of the bony defect, but the open hip surgery resulted in greater postoperative morbidity.

Adolescent↗
PubMed1999

Secondary alveolar bone grafting using milled cranial bone graft: a retrospective study of a consecutive series of 100 patients.

OBJECTIVE: The purpose of this study was to evaluate the outcome of secondary bone grafting of alveolar clefts using milled cranial bone graft. PATIENTS: The study included a consecutive series of 100 patients who were operated on between 1986 and 1995 by a single senior surgeon. MEASUREMENTS: The patients were divided into four groups; (1) unilateral alveolar cleft or (2) bilateral alveolar cleft, (3) before eruption of the canine teeth or (4) after eruption. Follow-up ranged from a minimum of 12 months to 10 years, and evaluation included a physical examination, medical photography, orthodontic reports, and a panorex X-ray and/or a three-dimensional computed tomography scan of the maxilla produced using Denta-scan software. Patient outcomes were judged to be good, acceptable, or poor. Patients who developed any fistula or required regrafting were defined as poor outcomes. RESULTS: The combined good and acceptable outcomes represented 83% of the entire consecutive series. These two groups were defined as successful outcomes. In patients with unilateral and bilateral clefts who were under 12 years old, the success rate was 90% and 88%, respectively. In patients grafted following full canine eruption (>12 years old), success rate decreased to 83% in patients with unilateral and 66% in bilateral clefts, respectively. CONCLUSIONS: Our results support the use of milled cranial bone graft, which produces a stable closure of the alveolar cleft with good contour and support for adjacent tooth eruption. Our data further support the conclusion by others that outcomes of early secondary grafting are superior to delayed grafting. The experience presented here, including the success rate, ease of harvesting, and minimal morbidity, makes the cranium our preferred donor site for alveolar cleft grafting.

Adolescent↗
PubMed1999

A multidisciplinary approach to the healing of cranial and residual maxillary cleft defects by means of allogenous demineralized osseous implants and polylactic acid casts in dogs.

OBJECTIVE: The aim of this study was to evaluate the healing of artificially induced bony defects in dogs by means of demineralized allogenous bone powder (DBP) implants covered with polyhydroxy lactic acid (PLA) casts compared with DBP implants without the casts. DESIGN: Prospective animal study. SETTING: Research university. SAMPLE: Following a pilot study in which two dogs were used, four mongrel dogs between the ages of 18 and 24 months and weighing approximately 20 kg were used as subjects. INTERVENTIONS: Each experimental animal had bilateral maxillary alveolar clefts created. In a later procedure, each defect was repaired with a DBP implant, half of which were covered with a PLA96 matrix. Each animal also had a circular defect created in each parietal bone that was immediately covered with DBP implants, half of which were similarly covered with a PLA96 disk. MAIN OUTCOME MEASURE: Repeated technetium-99m methylene-diphosphate (99mTC MDP) uptake measurements were performed to evaluate bone metabolism during the healing period, while at relevant intervals, radiographs were taken of the healing alveolar cleft defects to register bone repair. After 1 year, the animals were euthanized for macroscopic and histologic evaluation. RESULTS: Histologically, the grafts covered with PLA96 were at a more advanced stage of healing than those without, and the cranial defects similarly were more advanced in the healing process than the alveolar defects. Uptake of 99mTC MDP into the cranial implants was at its maximal level after 1 week and then gradually decreased until, after 7 weeks, it was not significantly different from zero. Cranial defects covered with a PLA95-enhanced implant showed a mean maximum count rate of 275, while the plain DBP side showed a mean maximal count rate of 150. Alveolar defects with the plain DBP implant showed a maximum count rate in the first week; those with the PLA95 enhanced implant showed maximum uptake during the second week. On both sides, there was a gradual decrease to the base value in the seventh week. The mean maximum count on the PLA96-enhanced side was 285, while on the plain DBP side, the corresponding value was 320. CONCLUSION: Although an advantage of the combination was established for parietal cranial defects, no advantage was seen for alveolar cleft defects in this experimental setup.

Alveoloplasty↗
PubMed1999

Advantages of percutaneous hollow needle technique for iliac bone harvest in alveolar cleft grafting.

OBJECTIVE: To evaluate the percutaneous hollow needle technique for bone harvest to determine if morbidity from the bone donor site can be reduced significantly. METHODS: A retrospective chart review was performed evaluating all patients undergoing alveolar bone grafting at our institution from January 1992 through December 1996. Patients who underwent additional major procedures were excluded. Group I consisted of 12 patients in whom the percutaneous technique was utilized. The patients had an average age of 11.1 years (range: 8 to 15 years). Six were male and six were female. One had a bilateral cleft. Group II consisted of 15 patients in whom the conventional open technique for iliac crest bone harvest was used. They had an average age of 13.1 years (range: 7 to 31 years). Six were male and nine were female. Two had bilateral clefts. Minimum follow-up was 6 months. We evaluated intraoperative blood loss, total postoperative analgesia requirement, and length of hospital stay based on a retrospective hospital chart review. RESULTS: A significant difference was found between the two groups regarding intraoperative blood loss (group I: 83.3 cm3, group II: 208 cm3; p = .0015), postoperative total analgesia requirement (group I: 0.04 mg/kg, range: 0 to 0.17 mg/kg; group II: 0.34 mg/kg, range: 0.03 to 0.74 mg/kg; p = .0002), and length of hospital stay (group I: 1.0 days, group II: 2.13 days; p = .0001). There was no significant change in these results when bilateral clefts were excluded. CONCLUSION: Iliac bone graft harvest using the percutaneous hollow needle technique results in less blood loss, decreased postoperative pain, and shorter hospital stays compared with the open technique.

Adolescent↗
PubMed1999

Presurgical nasoalveolar molding in infants with cleft lip and palate.

Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. In this paper, we present a paradigm shift from the traditional methods of presurgical infant orthopedics. Some of the problems that the traditional approach failed to address include the deformity of the nasal cartilages in unilateral as well as bilateral clefts of the lip and palate and the deficiency of columella tissue in infants with bilateral clefts. The nasoalveolar molding (NAM) technique we describe uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into normal form and position during the neonatal period. This technique takes advantage of the malleability of immature cartilage and its ability to maintain a permanent correction of its form. In addition, we demonstrate the ability to nonsurgically construct the columella through the application of tissue expansion principles. This construction is performed by gradual elongation of the nasal stents and the application of tissue-expanding elastic forces that are applied to the prolabium. Use of the NAM technique has eliminated surgical columella reconstruction and the resultant scar tissue from the standard of care in this cleft palate center.

Acrylic Resins↗
PubMed2000

The presurgical status of the alveolar cleft and success of secondary bone grafting.

OBJECTIVE: The primary purpose of this study was to evaluate presurgical status of the alveolar cleft site and success of secondary alveolar bone grafting. DESIGN: Thirty patient records were retrospectively reviewed. Patients selected for inclusion had isolated cleft of at least the primary palate. Patients with additional anomalies were not selected. The study population consisted of 15 female sites and 16 male cleft sites. There were two bilateral cleft lip and palate (CLP) patients and 28 unilateral CLP patients. The age at the time of the secondary alveolar bone grafting ranged from 7 years to 14 years, 4 months. SETTING: The study was conducted at the Cleft Palate Clinic at the University of Minnesota, School of Dentistry. METHOD: Presurgical radiographs taken at least 1 month prior to the secondary bone grafting and postsurgical radiographs taken at least 6 months after bone surgery were measured. Measurements included size of the cleft defect and bone support for distal and mesial teeth adjacent to the cleft. Evaluation of success was determined on the basis of postsurgical measurements of satisfactory, intermediate, and unsatisfactory outcomes. RESULTS AND CONCLUSION: The size of the cleft defect was not correlated with the success rate of the secondary alveolar bone grafting. If the amount of distal bone support for the mesial tooth was the same as those in a periodontally healthy individual, a satisfactory outcome was 5.8 times more likely. If the amount of mesial bone support for the distal tooth was the same as those in a periodontally healthy individual, the satisfactory outcome was 3.8 times more likely. Although not a primary purpose of the study, it was found that in this study population, if the patient was female, a satisfactory outcome was 3.8 times more likely.

Adolescent↗
PubMed2000

Secondary cleft lip nasal reconstruction: state of the art.

OBJECTIVE: This paper summarizes the state of the art in secondary cleft lip nasal reconstruction, distilled from the many papers written on the subject and from the author's experience with many of those procedures over the past 25 years. METHODS: The evaluation starts with the skeletal base and the need for LeFort 1 or alveolar bone grafting is discussed. The boney dorsum is next evaluated and a "monobloc" osteotomy considered. The cartilaginous dorsum follows and a "spreader-strut" graft is entertained. The tip cartilages are approached with either an open Potter or Dibbell preferred or replacement conchal graft if the tip has been destroyed by previous surgery. The skin envelope is then adjusted using methods described by Tajima, Dibbell, and Bardach.

Alveoloplasty↗
PubMed2000

Quantitative 3D maxillary arch evaluation of two different infant managements for unilateral cleft lip and palate.

OBJECTIVE: A two-institution retrospective study was undertaken to determine whether two different prepalatoplasty protocols quantitatively affect maxillary arch morphology in infants with complete unilateral cleft lip and palate (UCLP). DESIGN: Serial maxillary dental casts, obtained at regular intervals through the first 18 months of life from preintervention until palatoplasty were evaluated quantitatively using computer-assisted three-dimensional digitization and analysis for three populations: institution 1 (protocol 1), institution 2 (protocol 2), and unaffected individuals (neither cleft nor treatment). Sequential UCLP patients from institution 1 were matched for age and initial alveolar cleft width, sex and cleft side having been demonstrated to be nonsignificant, with UCLP patients from institution 2 and to unaffected individuals for age for the analysis. SETTING: Both treatment institutions are well-established regional interdisciplinary cleft centers. Institution 1 is located in a tertiary, academic children's hospital in a metropolis within a primarily agrarian region of the Midwest; institution 2 is a freestanding private clinic located in a small city within a primarily agrarian region of an eastern state; the unaffected population is a historic archive acquired in the 1930s. Data acquisition (model digitization) and computer processing were performed at institution 1. PATIENTS: Eighty-five casts of 28 infants from institution 1, 106 casts of 31 infants from institution 2, and 68 casts of 29 unaffected infants were analyzed. All infants had alginate impressions taken prior to intervention and at several additional 6-month intervals after that, consistent with each institution's treatment protocol. INTERVENTIONS: At institution 1, patients with UCLP underwent lip adhesion and placement of a passive alveolar molding plate at 7 weeks of age, definitive cheiloplasty at 7 months of age, and one-stage palatoplasty at 14 months of age. At institution 2, patients with UCLP underwent definitive cheiloplasty at 3 months of age, had no maxillary orthopedics, and had vomer flap hard palate repair at 12 months of age and soft palate repair at 18 months of age. MAIN OUTCOME MEASURES: The outcome measures included directly digitized (cleft segment and hemialveolar ridge lengths) and derived (alveolar base width, alveolar cleft gap, maxillary frenum-alveolar base perpendicular angle, and rates of change over time of digitized cleft segment and hemialveolar ridge lengths) features. The data were assessed by comparing simple linear regression lines and an unpaired, two-tailed t test. RESULTS: Prior to initiating therapy, there were no statistically significant differences between the two populations with clefts. However, both populations with clefts differed significantly from unaffected individuals (p < .001), with increased maxillary base widths and larger perpendicular/frenum angles. At the time of palatoplasty, the two populations with clefts had statistically significant differences between them in the maxillary base width (p < .01) and the cleft gap distance (p < .05). The base width of institution 1 did not differ significantly from that of widths of unaffected children, and that of institution 2 was significantly less, although the latter had already received first-stage palate repair. Alveolar segment growth rates were similar for the greater and lesser segments, respectively, and the left side hemialveolus of both groups. The growth rate for the noncleft side hemialveolus of institution 2 exceeded (p < .05) that of both institution 1 and unaffected patients. CONCLUSION: Two different regimens for the initial management of UCLP can significantly affect maxillary alveolar arch growth with respect to the treatment used and in comparison with unaffected controls.

Age Factors↗
PubMed2001

Factors related to relapse after Le Fort I maxillary advancement osteotomy in patients with cleft lip and palate.

OBJECTIVE: To identify factors associated with relapse after maxillary advancement in cleft lip and palate patient. SUBJECTS: Seventy-one cleft lip and palate patients underwent Le Fort I maxillary advancement osteotomy between 1988 and 1998, and 58 patients (42 unilateral cleft and 16 bilateral cleft) with complete data were investigated for relapse by clinical and cephalometric analysis. The clinical follow-up period ranged from 1.5 to 8.5 years (mean 2.5 years). RESULTS: Horizontal advancement averaged 6.9 mm. There was a significant correlation between surgical movement and postoperative relapse in both the horizontal and vertical planes. In vertical repositioning, 15 patients had maxillary intrusion and 31 had inferior repositioning. There was a significant difference between the intrusion group and the inferior repositioning group. There was a significant correlation between surgical and postoperative rotation regardless of the direction. Other factors were evaluated by the horizontal relapse rate. Type of cleft and the rate of relapse were statistically associated. A relapse was more likely to occur in patients with bilateral cleft. There were no significant associations with the rate of relapse in type of operations or previous alveolar bone grafting. There was no significant correlation between the rate of relapse and the number of missing anterior teeth, postoperative overbite and overjet, and age at operation. Four of 71 patients experienced major relapse, and 3 of them underwent jaw surgery again. CONCLUSIONS: Based on clinical and cephalometric analysis, two-jaw surgery should be performed in cases of severe maxillary hypoplasia, and overcorrection may be useful in inferior repositioning or surgical rotation. Special attention should be paid to the patient with bilateral cleft, multiple missing teeth, or shallow postoperative overbite.

Adolescent↗
PubMed2001

Secondary bone grafting of alveolar clefts: a densitometric comparison of iliac crest and tibial bone grafts.

OBJECTIVE: To evaluate changes in the optical density of secondary alveolar cleft bone grafts obtained from two different donor sites over time and to determine whether one donor site gives a higher recipient bone density than the other. METHODS: A prospective study was performed evaluating 40 healthy patients with congenital cleft lip and palate undergoing secondary alveolar bone grafting, 20 (14 boys and 6 girls) having iliac crest and 20 (12 boys and 8 girls) receiving tibial bone grafts. Bone harvest and grafting was carried out by one operator (G.P.). Optical density of iliac and tibial grafts measured using a computerized densitometer, was compared at 6 days, 6 weeks, and 3 months. Due to interference from orthodontic appliances, optical density measurements for 16 subjects were not possible, and these patients were excluded from the study. The length of hospital stay postoperatively for both grafting procedures were recorded. RESULTS: A significant decrease in relative bone density was demonstrated during the 3-month postoperative period in both iliac and tibial bone graft groups (p < .05). The difference in densities between iliac crest and tibial groups were not significantly different at any of the time points (paired t test, p > .05). Subjects undergoing iliac crest grafts stayed an average of 5 days in the hospital postoperatively, compared with subjects with tibial grafts who stayed an average of 3 days postoperatively. CONCLUSION: Optical density measurements of bone grafted into alveolar clefts, reported here for the first time, provide a valuable objective assessment of graft progress. Tibial and iliac crest grafts gave similar optical densities at recipient sites over the first 3 months. Iliac crest grafts required significantly longer postoperative stay; an important consideration in selecting donor sites for secondary bone grafting.

Absorptiometry, Photon↗
PubMed2001

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 2: dentofacial outcomes and patient satisfaction.

OBJECTIVE: To describe facial development and appearance, quality of bone grafts, oral health, and patient/parent satisfaction, with clinical outcome, for children in two age cohorts born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. DESIGN: Cross-sectional outcome study. SETTING: Fifty National Health Service cleft centers. PARTICIPANTS: Children born with complete UCLP between April 1, 1982, and March 31, 1984, (12-year-olds) and April 1, 1989, and March 31, 1991 (5-year-olds). Data were collected for 239 5-year-olds and 218 12-year-olds. The parents of these children were also interviewed to determine levels of satisfaction with care received. MAIN OUTCOME MEASURES: Skeletal pattern, dental arch relationship, success of alveolar bone grafting, facial appearance, oral health status, and patient/parent satisfaction. RESULTS: Nearly 40% of 5- and 12-year-olds had poor dental arch relations, and 70% of 12-year-olds had midface retrusion. Fifteen percent of 12-year-olds had not received an alveolar bone graft, and only 58% of bone grafts that had been undertaken were successful. Twenty percent of 12-year-olds and 40% of 5-year-olds had untreated dental caries. Less than one-third of subjects had a good facial appearance as judged by a panel of experts. Levels of patient and parent satisfaction were generally high. CONCLUSION: A rigorous evaluation of cleft care in the United Kingdom reveals disappointing outcomes.

Alveoloplasty↗
PubMed2001

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 4: outcome comparisons, training, and conclusions.

OBJECTIVE: A critical appraisal of cleft care in the United Kingdom. DESIGN: Retrospective comparative study. SETTING: All National Health Service cleft centers in the United Kingdom. PATIENTS/PARTICIPANTS: Children born with unilateral complete clefts of the lip and palate between April 1, 1982, and March 31, 1984 (12-year-olds), and April 1, 1989, and March 31, 1991 (5-year-olds). Newly appointed and senior cleft clinicians. MAIN OUTCOME MEASURES: Skeletal pattern, dental arch relationship, success of alveolar bone grafting, dental health, facial appearance, oral health status, patient/parent satisfaction. CONCLUSIONS: This paper highlights the poor outcomes for the fragmented cleft care in the United Kingdom, compared with European centers. There is an urgent need for a review of structure, organization, and training.

Alveoloplasty↗
PubMed2001

Cleft lip and palate management by U.K. consultant oral and maxillofacial surgeons: a national survey.

OBJECTIVE: Following the report of the Clinical Standards Advisory Group (CSAG), a national survey of U.K. consultant oral and maxillofacial surgeons was performed to determine the current cleft lip and palate practice of this group prior to the implementation of proposed radical changes in the delivery of cleft services. The views of these surgeons regarding the proposed changes was also sought. DESIGN: An anonymous postal questionnaire sent to all 266 consultants in the U.K., which requested information on the practice of cleft surgery during a defined 1-year period (March 1997 through February 1998). It included the numbers and types of procedures performed, the involvement of multidisciplinary care, research and audit activity, and questions regarding the implementation of CSAG. RESULTS: One hundred ninety-one replies (72% response rate). Seventy-three surgeons were actively involved with mainly secondary cleft surgery. A varied number and range of procedures were undertaken, with most surgeons performing less than five of each procedure per year. Audit and research activity was 26%. The majority of both noncleft and cleft surgeons agreed with proposals made by CSAG (except for cleft osteotomy procedures). CONCLUSIONS: In the U.K. at present, there are many oral and maxillofacial surgeons performing mainly secondary cleft surgery; overall, the number of procedures performed by these surgeons per year is small. Intraspecialty referral is suggested to further improve patient outcome.

Alveoloplasty↗
PubMed2001

Mandibular bone graft material for reconstruction of alveolar cleft defects: long-term results.

OBJECTIVE: To analyze the long-term effect of mandibular bone as donor material in bone grafting of the alveolar process defect in patients with unilateral cleft lip and palate (UCLP), compared with iliac crest cancellous bone. METHOD: During a 7-year period, 101 UCLP patients were bone grafted, 57 cases with iliac crest cancellous bone and 44 with mandibular symphyseal bone. The long-term results with an observation time of more than 4 years were analyzed with respect to marginal bone level and dental and gingival condition in the grafted area. Complications were recorded. RESULTS: The bone level in the grafted area was satisfactory in both groups. Impaction of cleft-side canines was found in 35% of the patients in both groups. Patients with agenesis of the cleft side lateral incisor had significantly more impacted canines, compared with patients with a cleft-side lateral situated in the lesser maxillary segment, probably due to the fact that the lateral incisors help in guiding the canine down through the grafted area. The number of complications was scarce, although both groups demonstrated some gingival retraction with a longer crown length at the cleft side central incisor. CONCLUSION: The findings of this study have changed our strategy in bone grafting. Timing of orthodontic treatment and bone grafting has been more varied depending on the position and presence of teeth in the cleft area. Bone grafting of the alveolar process is not just a local treatment of a bony defect, but in respect to the burden of treatment, bone grafting of the alveolar process has to be planned in accordance with orthodontic treatment and maxillofacial growth.

Alveolar Process↗