Sheldon W. Rosenstein

Comparison of 2-D calculations from periapical and occlusal radiographs versus 3-D calculations from CAT scans in determining bone support for cleft-adjacent teeth following early alveolar bone grafts

OBJECTIVE This investigation was conducted to determine the agreement between three-dimensional (3-D) calculations from CAT scans and two-dimensional (2-D) calculations from standard dental radiographs in evaluating bone support for cleft-adjacent teeth after primary bone grafting. DESIGN This retrospective study utilized CAT scans and dental radiographs taken of the alveolar cleft in patients an average of 11 years after primary bone grafting. SETTING The subjects were patients treated by the Cleft Palate Team at Childrens Memorial Hospital and Loyola University Medical Center, Chicago, Illinois. PATIENTS Fourteen UCLP patients (9 males, 5 females) agreed to participate in this study by undergoing CAT scan assessment of their alveolar cleft sites. They also had to have periapical or occlusal radiographs of the grafted cleft site taken within 6 months of the CAT scan. INTERVENTIONS All patients underwent primary lip repair, placement of a passive palatal plate, primary alveolar bone grafting (mean age 6.4 months), and palatoplasty before 1 year of age. Major tooth movement through final orthodontics was completed by the time of the radiographic assessment. MAIN OUTCOME MEASURES CAT scan sections were reformatted and reconstructed to three-dimensionally calculate the percentage of root covered by bone support for the 15 teeth adjacent to the graft cleft sites. Dental radiographs of the same teeth were also traced and digitized. Percentages of root supported by bone were also established using the dental radiographs by dividing the amount of root covered by bone, by the anatomic root length. RESULTS A paired, two-sample t test revealed no significant differences between the two methods of assessment, while linear regression showed a statistically significant correlation between the CAT scan assessment and the percentages found on the radiographs. CONCLUSIONS Routine dental radiographs were able to estimate the total 3-D bone support for the roots of cleft adjacent teeth as determined by CAT scan to a statistically significant degree when groups where compared. The clinical significance for evaluation of individual cases was less impressive with a wide range of variability and a level of agreement that required acceptance of differences up to 25%.

The case of early bone grafting in cleft lip and cleft palate.

To date there are conflicting reports in the literature as to the efficacy of early maxillary orthopedic procedures and primary osteoplasty in newborns with complete clefts of the lip, alveolus, and palate. Ross accounts for the disagreement by stating that the critical variable may be the surgical procedure utilized in closing the palate, not necessarily the placement of the graft. Friede has also postulated that perhaps it is principally a difference in the graft techniques. Cephalometric evaluation of our sample at 13 years 11 months of age compared with a like sample wherein the primary osteoplasty had not been done showed the two samples to be clinically the same. We feel that in utilizing our sequence of procedures and carefully monitoring facial growth of these children we do not adversely influence facial growth and, in fact, present a more favorable maxillary segment alignment and teeth in better overall occlusion than if we had not done these procedures. From our results, we conclude that there should be no condemnation of the principle of this treatment because of individual failings and failures. Although differences in techniques can and do influence results, the concept of maxillary orthopedics and primary osteoplasty need not be thrust aside even if some techniques are found wanting.

A long-term retrospective outcome assessment of facial growth, secondary surgical need, and maxillary lateral incisor status in a surgical-orthodontic protocol for complete clefts.

&NA; In 1965, the cleft palate team at Childrens Memorial Hospital embarked on a new surgical‐orthodontic protocol in the habilitation of newborn complete cleft lip and palate cases. It brought the orthodontic effort into focus at birth and in planned sequence to correspond with the surgical procedures of lip closure, maxillary alveolar stabilization by means of an autogenous graft of the authors’ design, and complete palate closure, all within the first year of life. The purpose of this investigation is threefold: first, to review the authors’ previous publications and assess growth, secondary surgical need, and lateral incisor status of teeth adjacent to the cleft in a series of patients who have all followed a precise, early surgical/orthodontic protocol; second, to compare these cases with other collaborative studies wherein this protocol was not used; and third, to report on an additional 82 cases with regard to secondary surgical need and the status of teeth adjacent to the cleft. Methods of assessment have included cephalometric radiography, periapical and occlusal dental radiography, computer‐assisted tomography, plaster cast analysis, and intraoral and extraoral photography. The authors have demonstrated, along with other collaborative studies, that there is growth as good as other similar samples wherein there was no primary osteoplasty. In addition, the authors found their incidence of orthognathic surgery to be 18.29 percent; pharyngoplasty, 3.65 percent; and oronasal fistulas requiring surgical closure, 29.27 percent. In the case of unilateral complete clefts, 53.13 percent of those lateral incisors present adjacent to the cleft area were usable, and in bilateral cases, 57.77 percent were usable. The authors remain convinced after more than 35 years of following this successful protocol that early maxillary orthopedics and their technique of primary osteoplasty in planned sequence with lip and palate closure can produce a more favorable alignment of maxillary growth potential and, with comprehensive orthodontic treatment, can lead to teeth in a better overall occlusion than if these procedures had not been undertaken. (Plast. Reconstr. Surg. 111: 1, 2003.)

The case for early bone grafting in cleft lip and palate: a second report.

In 1982, the first long-term study of our early bone-grafting and infant maxillary orthopedic approach to newborn complete clefts of the lip, alveolus, and palate was published. The protocol and sequence of procedures were shown on the first 16 consecutively treated orthodontic patients, with a mean age of 14 years. Cephalometric analysis evaluated anteroposterior and vertical facial growth. This report follows the next 37 consecutively treated individuals in a similar manner and includes not only 20 complete unilateral clefts, but also 17 complete bilateral clefts. Results, when evaluated alone and in comparison with the original series, show once again that there are no adverse growth restraints and that early primary bone grafting in our protocol leads to teeth in better overall occlusion than if it had not been undertaken.

Timing of cleft palate closure should be based on the ratio of the area of the cleft to that of the palatal segments and not on age alone

Background: Retrospective and prospective serial spatiotemporal investigations were carried out primarily to determine whether the ratio of the size of the posterior cleft space relative to the palatal surface area limited laterally by the alveolar ridges can be used to select the appropriate time for surgical closure of the palatal cleft space. Two subsamples were compared to determine whether the size of the palate and velocity of palatal development in well growing cases differ from those in cases treated by vomer flap surgery. The prospective investigation asked whether presurgical orthopedics increases the rate of palatal growth and palatal size. Methods: Using the palatal casts of 242 male and female individuals from eight institutions in the United States and Western Europe that followed a variety of treatment protocols, separate serial analyses were conducted of well growing cases with excellent aesthetics, dental occlusion, and speech and a control series of 17 cases of various clefts of the lip and alveolus and/or soft palate but no clefts in the hard palate. Twelve groupings of cases were established depending on their institutional location and type of cleft. Results: Among the various institutions in the study, palatal growth rates and size were statistically similar. Growth in the various clinical series (size, mm2) was less than that of the control series. The ratio of cleft space size to palatal surface area medial to the alveolar ridges was 10 percent or less at 18 months of age in most cases. There was no statistical difference in total surface size between groups, except for one series whose total growth size was least of all. Right and left lateral palatal segments, whether large or small, grew at the same rate. The sample of bilateral cases was too small for statistical comparisons. Presurgical orthopedics did not stimulate palatal growth. The coefficient of variance was less than 10 percent in all measurements. Conclusions: Delaying all cleft closure surgery until 5 years of age and older is unnecessary to maximize palatal growth. The best time to close the palatal cleft space is when the palatal cleft size is 10 percent or less of the total palatal surface area bounded laterally by the alveolar ridges. The 10 percent ratio generally occurs between 18 and 24 months but can occur earlier or later. There is more than one good type of palatal cleft closure surgery.

Orthognathic surgery in cleft patients treated by early bone grafting.

For the past 25 years at Childrens Memorial Hospital in Chicago a protocol has been followed for complete clefts that involves placement of an infant maxillary orthopedic appliance prior to lip closure, surgical closure of the lip, autogenous split-rib grafts to the alveolus to stabilize maxillary segments, and palatal closure, generally within the first year of life. The oldest 36 patients whose skeletal growth was for all practical purposes finished have been followed to determine the need for and type of orthognathic surgery. Of the total sample, 8 patients (22.2 percent) required some type of sagittal orthognathic surgery (1 patient in this group also required vertical maxillary alignment) and 2 patients required maxillary augmentation only in the form of an onlay graft. This report may serve as a baseline for others who wish to report on the incidence and type of orthognathic surgery in their cleft palate centers.

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

&NA; 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. (Plast. Reconstr. Surg. 99: 1840, 1997.)

The Eurocleft Study: Intercenter study of treatment outcome in patients with complete cleft lip and palate.

May we add our kudos to the recently published four-part article concerning the Eurocleft intercenter study. The scope of the work is impressive. Much has been learned already from this fine work, and needed information will continue to be forthcoming. Having thus stated the obvious, may we point out what we feel is a glaring and misleading statement in Part 3: Dental Arch Relationships (pp. 78–82). The statement is somewhat incomplete and therefore prejudicial. Even more damning is what it does not say. We refer to page 81, in the next to last paragraph, which states that this was the only center where primary bone grafts were part of the early protocol and that they subsequently found that 50% of the patients eventually needed orthognathic surgery. It is then stated, ‘‘The finding that primary bone grafting is associated with poor growth of the maxilla is in agreement with earlier studies (Friede and Johanson, 1974, 1982; Ross, 1987; Brattström et al., 1991).’’ Indeed, the statement is true, but what it does not state (thus confirming prior prejudicial attitudes in reference to primary bone grafts) and what the authors could have added or merely stated elsewhere, is the phrase ‘‘as executed in the technique and protocol in the center in this study.’’ One should never lose sight of the fact that when these procedures were initially utilized (and this study was started), grafts often were placed at the time of lip closure, separately, or even at the time of palate closure. Often they were placed over large bony voids accompanied by extensive undermining. There were no common denominators other than that they were all done within approximately the first year of life; one northern European center undermined extensively and raised large double transpalatal flaps. Without this knowledge, one readily can understand the present-day lack of objectivity in assessing the long-term veracity of early bone grafts. As presented in this current publication, the information merely perpetuates previously held misconceptions and closes down an open mind. In contrast, we have been part of a well-defined protocol, initiated in the 1960s, that included type and timing of primary osteoplasty. The primary graft is basically a small, autogenous subperiosteal onlay rib graft placed across the maxillary alveolus, with minimal undermining, after the segments have been aligned in close approximation. Long-term studies have consistently shown no growth attenuation and a 35-year retrospective study of 82 complete cleft lip and palate cases (mean age, 17.5 years; Rosenstein, et al., 2003) showed an incidence of orthognathic surgery to be 18.29%! Indeed, one should keep in mind the old adage of the baby and the bath water.