Timing of Alveolar Bone Grafting Determines Different Outcomes in Patients With Unilateral Cleft Palate

Abstract

The objective of the current study was to assess the outcome of the alveolar bone grafting (ABG) in patients with cleft palate. Thirty-one patients with complete unilateral cleft lip and palate were prospectively divided into 2 groups according to the timing of surgery: (1) secondary ABG (SABG), undertaken during mixed dentition (n = 16); and (2) tertiary ABG (TABG), undertaken during permanent dentition (n = 15). Septum height was assessed using cone beam computed tomography in 3 views (buccal, intermediate, palatal) and classified according to the modified Bergland Index, which scores the results into 5 types according to the height of the neoformed bone septum (excellent: septum with a normal height; good: septum with minor deficiency; regular: marginal defect of >25% of the root length; bad: bone deficiency on the nasal aspect; and failure). In the SABG group, 6 to 12 months postoperatively, 75% of the patients were classified as having excellent/good conditions and 25% as having regular/bad conditions. No patients were observed as having failure conditions. In the TABG group, 53% of the patients were classified as having excellent/good, 21% were classified as having regular/bad conditions, and 26% were classified as having failure conditions. Significantly better outcomes were observed for the SABG group when compared with the TABG group. In conclusion, the age at which ABG is performed is a factor that impacts on the surgical outcome. Specifically, increasing age is associated with worse outcomes.

Increase in Age Is Associated With Worse Outcomes in Alveolar Bone Grafting in Patients With Bilateral Complete Cleft Palate

“…An unexpected finding of the current study was that the percentages of successful results obtained in bilateral clefts, 96% and 65% for the SABG and TABG, respectively, were higher than those in unilateral clefts analyzed in a previous study (75% and 53%, respectively). 10 Our initial hypothesis was that the worse outcomes should be expected for bilateral cases because of premaxillary mobility, considered a crucial factor for grafting success. The reasons why better surgical outcomes were observed for bilateral clefts remain unclear and should be further investigated.…”

“…10 Periapical images were classified into 5 types based on the analysis of the bone septum height: E (excellent: septum with a normal height), G (good: septum with minor deficiency of the interdental bone), R (regular: graft with sufficient bone for the canine eruption but tooth movement potentially unsuccessful or a marginal defect of 925% of root length), B (bad: bone deficiency on the nasal aspect preventing tooth movement), or F (failure: complete resorption of the bone graft). Types E, G, and R could occur in association with the B type.…”

“…11 The 3 periapical images were classified individually, thus forming a triple rating (eg, EGG, GRR, or FFF), allowing for the analysis of the bone graft in different depths and not only in a single two-dimensional view, as in conventional periapical radiographs. 10,14 For the descriptive analysis, clefts were distributed into the 5 outcome types previously described, and the data were expressed as percentage. For statistical purposes, scores of neoformed bone septum were graded as follows: E = 1, G = 2, R = 3, B = 4, and F = 5, meaning that the lower the value, the better the surgical outcome.…”

“…Previous studies suggested that better surgical outcomes are achieved when ABG is performed during the mixed dentition. 7,9,10 However, anatomic defects determined by bilateral clefts, such as premaxillary prognathism and mobility, make ABG a more complex procedure, with a higher chance of failures, when compared with unilateral clefts.…”

“…The method has proved to be effective for evaluating the surgical outcomes of ABG, as in a study of our group, which investigated ABG outcomes in unilateral patients. 10 Considering that a few controlled studies have investigated the outcomes of ABG surgery in bilateral clefts 2,7,11,12 and that the rehabilitation protocol of subjects with craniofacial anomalies should be based on scientific evidence, as recommended by the World Health Organization, 13 this prospective study aimed at evaluating the surgical outcomes of ABG in bilateral cases performed at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, São Paulo, Brazil, by means of CBCT.…”