GP2b - Outcomes of Secondary Alveolar Bone Grafting for Alveolar Clefts: A Retrospective Analysis

Abstract: Cleft lip and palate (CLP) patients with clefts in the tooth-bearing alveolar bone typically undergo alveolar bone grafting (ABG) as part of their sequential management. Secondary ABG is generally performed before the eruption of the permanent canine to close oral-nasal fistulae and achieve alveolar ridge continuity. This allows for bone support for the eruption of the permanent dentition into the cleft. While variations in clinical technique have been described in the literature, there is a sparsity of literature that examines the impact of these factors on the outcomes of ABG. This study focuses on anterior iliac crest bone grafting (AICBG) for CLP patients and examines the factors associated with clinical and radiographic success.

Clinical data from Shriners Children’s Texas in Houston was evaluated for patients aged 7 to 21 with secondary alveolar bone grafting for cleft lip and palate. A total of 142 patients were identified as having had adequate postsurgical imaging and follow-up of at least 6 months. A single reader (SA) assigned Bergland and Kindelan index scores to each postoperative radiograph. Clinical success also was determined for each patient. The three factors defining clinical success were the complete closure of the oronasal fistula, the absence of postoperative infection or wound breakdown, and no need for re-grafting. Twenty-seven independent variables, including demographics, surgical techniques, and perioperative care, were collected and analyzed with descriptive and analytical statistics to identify their association with ABG success or failure.

Of the 142 patients, 130 (91.5%) of cases closed the oronasal fistula, 131 (92.2%) had no presence of wound breakdown or postoperative infection, and 137 (96.4%) did not require re-grafting. In 123/142 (86.6%) cases, all three criteria for clinical success were met, 120/142 (84.5%) patients were deemed radiographically successful (Bergland and Kindelan index scores of 1 or 2), and 109/142 (70.4%) patients met both radiographic and clinical criteria for success.

Increased patient age was associated with a significant increase in wound breakdown or infection. Patients with larger cleft sizes were highly associated with a greater likelihood of wound breakdown or infection and need for re-grafting. Using an acellular dermal matrix (ADM) (n = 61) had an odds ratio of 7.1 of developing either wound dehiscence or postoperative infection when compared to those patients where an ADM was not used. Adequate preoperative oral hygiene was significantly associated with fewer incidences of need for re-grafting and postoperative wound dehiscence or infection.

The success of secondary ABG in cleft lip and cleft palate patients is multivariate and is not dependent on any single factor or variable. However, the data presented in this study can aid the surgeon in determining techniques associated with optimal outcomes. These data also can help educate patients who may be at higher risk for procedural complications, such as those with poor oral hygiene preoperatively.

References
1. Kim J, Jeong W. Secondary bone grafting for alveolar clefts: surgical timing, graft materials, and evaluation methods. Arch Craniofac Surg. 2022 Apr;23(2):53-58. doi: 10.7181/acfs.2022.00115.
2. McIntyre GT, Devlin MF. Secondary alveolar bone grafting (CLEFTSiS) 2000-2004. Cleft Palate Craniofac J. 2010 Jan;47(1):66-72. doi: 10.1597/08-165.1.