Comparative Outcomes of Primary Gingivoperiosteoplasty and Secondary Alveolar Bone Grafting in Patients with Unilateral Cleft Lip and Palate :

Fresh autogenous cancellous bone is ideal for secondary alveolar cleft bone grafting because it supplies living, immunocompatible bony cells that integrate fully with the maxilla and are essential for osteogenesis. Recent animal studies have shown that the dynamics of cancellous inlay bone grafts are different from those of cortical onlay bone grafts, and they refute the assumption that membranous bone grafts are superior to endochondral bone grafts because of their embryological origin. These studies prove that inlay endochondral cancellous specimens have a higher percentage increase in actual bony volume than cortical membranous and cortical endochondral inlay bone grafts. There are various donor sites for secondary alveolar cleft bone grafts. Currently the main sites for autogenous cancellous bone are iliac crest, calvarium, mandibular symphysis, and tibia. Some authors have suggested that the iliac crest donor site causes an unacceptably high degree of postoperative morbidity, but it is still the first choice for secondary alveolar cleft bone grafts and should not be rejected solely because of such concerns. Recombinant human bone morphogenetic protein-2 (rhBMP-2) is now an attractive bony substitute that promotes the differentiation of pluripotential cells into bone-forming cells that lay down new host bone in the site of the defect. Much more research and development are necessary to find a suitable carrier for rhBMP-2, and to study the properties of newly formed bone that it has induced before it can be a substitute for autogenous bone.

To assess the radiographic outcome of secondary alveolar bone grafting in individuals with nonsyndromic unilateral or bilateral cleft lip and palate using cone beam computed tomography. This prospective study was conducted at the University of California at San Francisco Center for Craniofacial Anomalies on 21 consecutive nonsyndromic complete cleft lip and palate individuals between 8 and 12 years of age who required alveolar bone grafting. Seventeen unilateral and four bilateral cleft lip and palate individuals had preoperative and postoperative cone beam computed tomography scans that were analyzed using Amira 3.1.1 software. The average volume of the preoperative alveolar cleft defect in unilateral cleft lip and palate was 0.61 cm(3), and the combined average volume of the right and left alveolar cleft defects in bilateral cleft lip and palate was 0.82 cm(3). The average percentage bone fill in both unilateral cleft lip and palate and bilateral cleft lip and palate was 84%. The outcome of alveolar bone grafting was assessed in relation to (1) type of cleft, (2) size of preoperative cleft defect, (3) presence or absence of lateral incisor, (4) root development stage of the maxillary canine on the cleft side, (5) timing, and (6) surgeon. None of these parameters significantly influenced the radiographic outcome of alveolar bone grafting. Secondary alveolar bone grafting of the cleft defect in our center was successful, based on radiographic outcome using cone beam computed tomography scans. Volume rendering using cone beam computed tomography and Amira software is a reproducible and practical method to assess the preoperative alveolar cleft volume and the adequacy of bone fill postoperatively.

To determine the postoperative morbidity of harvesting cancellous bone from the anterior iliac crest for treating secondary cleft alveolus patients. Twenty-four patients treated for alveolar clefts in the Oral and Maxillofacial Surgery unit at the Jordan University Hospital were included. Medical notes were reviewed for intraoperative and postoperative complications; patients were interviewed to fill a questionnaire on postoperative recovery. The donor site was evaluated for the following factors: chronic pain, neurapraxia of the lateral femoral cutaneous nerve, abnormal gait, altered sensation over the scar, skin tenderness, bone tenderness, deformity of the bony contour, and scar length and width were measured. Age at the time of surgery was 14.0+/-4.1 years (mean +/- SD), and follow-up was 23.2+/-19.3 months. Patients spent a median of 3 days in hospital (range=2-4 days), patients walked normally after 10.4+/-13.2 days and resumed normal activities, including sports, after a mean of 16.0+/-19.6 days. Two patients had neurapraxia of the lateral femoral cutaneous nerve (8%), 2 reported mild residual scar tenderness (8%) and 1 of the latter complained of tenderness on palpating the iliac crest (4%). Harvesting cancellous bone from the anterior iliac crest in young patients is well-tolerated, allows early resumption of normal activities, has no effect on growth, has minimal morbidity, and a reasonable esthetic outcome.