A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Dentistry in the branch of Maxillofacial and Oral Surgery 31 May 2018. / Aim The aim of this retrospective study was to determine the outcomes of secondary alveolar bone grafts (SABG) in cleft patients treated at the Wits Dental Hospital at the Charlotte Maxeke Johannesburg Academic Hospital. Objectives To record the demographic data of patients who had secondary alveolar bone grafts, and to assess the outcomes of SABG by evaluating clinical variables and the quantity of bone post SABG. Methods Records of 19 patients with a total of 23 clefts were examined to evaluate the amount of bone at the cleft site following secondary alveolar bone graft. Socio-demographic information was collected as well as the clinical variables of the type of graft used, canine eruption, keratinised tissue around teeth close to the cleft, and closure or persistence of any oronasal fistula. The amount of bone at the graft site was measured on CBCT images using the Chelsea scale. Comparisons of Chelsea scale scores and CBCT findings were carried out. SPSS ® 24 was used to analyse the data. All statistical tests were conducted at 5% significance level. Results Most (52%) patients were male, with 57% having left unilateral cleft. The majority of them received autogenous bone grafts from the chin. Most (65.2%) of the patients showed good clinical outcomes, whilst showing evidence of bone resorption in and around the graft site on CBCT images. Fifteen of the patients were considered to have partial alveolar graft resorption. Conclusion In the majority of patients, 3D CBCT images revealed bone resorption in areas that 2D images gave an impression of presence of bone. However, the majority of patients indicated good clinical outcomes despite the poor radiological findings. / LG2018

OBJETIVO: Determinar a efetividade de manobras padronizadas de drenagem linfática manual (DLM) na redução do edema facial, na distância interincisal máxima ativa e no quadro álgico de pacientes submetidos à cirurgia de Enxerto Ósseo Alveolar (EOA). METODOLOGIA: Esta pesquisa analisou 51 indivíduos com fissura labiopalatina reparada, entre 10 e 15 anos de idade, submetidos ao EOA no Hospital de Reabilitação de Anomalias Craniofaciais-USP, divididos em 2 grupos, grupo tratamento (n=29, 12 homens e 17 mulheres) e grupo rotina (n= 22, 15 homens e 7 mulheres). No grupo tratamento foram aplicadas manobras de DLM padronizadas diferentemente daqueles do grupo rotina. Foram realizadas nos dois grupos avaliações do edema facial por meio das medidas da linha 1 (distância da base da asa nasal ao tragus) e linha 2 (distância da base da asa nasal à implantação inferior do pavilhão auricular), na hemiface operada nos períodos pré-operatório (Pré), segundo (2ºPO) e quarto pós-operatório (4ºPO). Também foram realizadas as medidas da distância interincisal máxima ativa nos mesmos períodos. A Escala Analógica da Dor (EAD) foi aplicada no 1º, 2º, 3º e 4º períodos pós-operatórios. Adicionalmente, no grupo tratamento, após a terapia de DLM, foram realizadas perguntas sobre dor, relaxamento e sono. RESULTADOS: Houve redução do edema facial no grupo tratamento do 2ºPO para o 4ºPO o que não ocorreu no grupo rotina. As medidas da distância interincisal apresentaram aumento entre o 2ºPO e 4ºPO nos dois grupos estudados. Na avaliação da EAD, o grupo tratamento mostrou ausência de dor no 3ºPO enquanto o grupo rotina somente no 4ºPO. No grupo tratamento, a totalidade dos indivíduos relataram que a dor diminuiu, e que se sentiram mais relaxados após a DLM, nos 3 períodos avaliados. Relataram também em muitos casos que a DLM teve efeito facilitador na indução ao sono durante a DLM. CONCLUSÕES: As manobras padronizadas de DLM aplicadas da maneira proposta produziram redução significante do edema facial, aumento da distância interincisal máxima ativa, redução do quadro álgico no grupo tratamento comparativamente ao grupo rotina. Esses dados reforçam a hipótese de que a DLM proposta foi efetiva contribuindo de maneira importante na recuperação do paciente submetido à cirurgia de EOA. / OBJECTIVE: To determine the effectiveness of standardized manual lymphatic drainage (MLD) maneuvers in reducing facial swelling, maximum interincisal active distance and pain of patients undergoing surgery for Alveolar Bone Grafting (ABG). METHODS: This study examined 51 individuals with repaired cleft lip and palate, aged 10 to 15 years old, who underwent ABG at the Hospital for Rehabilitation of Craniofacial Anomalies- USP, divided into two groups: treatment group (n = 29, 12 men and 17 women) and routine group (n = 22, 15 men and 7 women). In the treatment group MLD standardized maneuvers were performed differently from those of the group routine. In both groups evaluation of facial swelling was performed by measuring the distance from the ala nasi to the tragus (line 1) and the distance from the ala nasi to the inferior portion of the ear auricle (line 2), in the operated side, preoperatively, and at the second and the fourth postoperative (PO) day. The maximum active interincisal distance was measured during the same periods. The Pain Analog Scale (PAS) was applied at the first, second, third and fourth days after ABG. Additionally, patients from the treatment group, were asked about pain, relaxation and sleep after MLD therapy. RESULTS: There was a reduction of facial edema in the treatment group from the 2nd to 4th PO what was not observed the routine group. Interincisal distance increased between the 2nd and 4th PO in both groups. PAS evaluation has shown that patients from the treatment group present no pain already at 3rd PO. In the routine group this occurred only at 4th PO. All the subjects from treatment group reported decrease of pain, and patients reported felt more relaxed after the MLD, at the three postoperative evaluated. Many patients reported that MLD had a facilitative effect on inducing sleep during MLD. CONCLUSIONS: The standardized MLD maneuvers applied in the proposed manner produced significant reduction of facial swelling, increase of the maximum active interincisal distance, reduction of the pain in the treatment group as compared to the routine group.These Abstract data reinforce the hypothesis that the proposed MLD is a effective procedure for the recovery of the patients undergoing ABG surgery.

Objetivo: O propósito deste estudo é avaliar a regeneração óssea nos defeitos alveolares congênitos com proteína morfogenética óssea (rhBMP-2) em membrana de colágeno reabsorvível. Material e Métodos: Vinte e quatro pacientes com fissura labiopalatina completa unilateral, em momento ideal, foram distribuídos ao acaso entre os grupos controle (porção medular de ilíaco) e teste (rhBMP-2 em membrana de colágeno absorvível). Foram avaliados em 6 meses e 1 ano de pós-operatório por meio de radiografias periapicais e tomografias computadorizadas pela escala de Chelsea. Resultados: Encontraram-se índices de sucesso quanto à altura do septo ósseo semelhantes entre os grupos: em 6 meses, na análise radiográfica, 81,82% no controle e 91,67% no teste; em 1ano, 83,33% no controle e 100% no teste; na análise tomográfica, observaram-se 70% no controle e 91,67% no teste em 6 meses, 75% no controle e 100% no teste em 1 ano. Na análise volumétrica, os valores encontrados foram 45,34% de preenchimento ósseo da fissura no grupo controle aos 6 meses e 40,63% no teste, 53,33% no controle e 53,1% no teste em 1 ano. Não houve diferença estatisticamente significante. Conclusão: A rhBMP-2 em membrana reabsorvível de colágeno produziu resultados semelhantes ao enxerto autógeno de medula de crista ilíaca ao reparar defeitos alveolares de fissuras labiopalatinas completas. / Objective: The purpose of this study is to assess the bony regeneration of alveolar clefts using bone morphogenetic protein (rhBMP-2) in a collagen sponge carrier. Material and Methods: Twenty four patients with unilateral complete cleft lip and palate, in the very best moment, were randomly assigned to groups control (iliac crest cancellous bone) and test (rhBMP-2 in an absorbable collagen sponge). They were evaluated 6 months and 1 year postoperative with periapical radiographs and computed tomographs using Chelsea scale. Results: For control group, radiographic examination revealed success index for bone height 81,82% 6 months and 83,33% 1 year postoperative; for test group, findings were 91,67% first control and 100% 1 year. Computed tomograph revealed 70% 6 months and 75% 1 year for control group, 91,67% first control and 100% 1 year for bone height test group. Volume ratios were 45,34% bone filling 6 months and 53,33% 1 year for control group and 40,63% 6 months and 53,1% 1 year for test. There was no statistical significance. Conclusion: rhBMP-2 in a collagen sponge carrier induced bony regeneration close to that from iliac crest cancellous bone to repair complete alveolar clefts.

Objetivo: O propósito deste estudo é avaliar a regeneração óssea nos defeitos alveolares congênitos com proteína morfogenética óssea (rhBMP-2) em membrana de colágeno reabsorvível. Material e Métodos: Vinte e quatro pacientes com fissura labiopalatina completa unilateral, em momento ideal, foram distribuídos ao acaso entre os grupos controle (porção medular de ilíaco) e teste (rhBMP-2 em membrana de colágeno absorvível). Foram avaliados em 6 meses e 1 ano de pós-operatório por meio de radiografias periapicais e tomografias computadorizadas pela escala de Chelsea. Resultados: Encontraram-se índices de sucesso quanto à altura do septo ósseo semelhantes entre os grupos: em 6 meses, na análise radiográfica, 81,82% no controle e 91,67% no teste; em 1ano, 83,33% no controle e 100% no teste; na análise tomográfica, observaram-se 70% no controle e 91,67% no teste em 6 meses, 75% no controle e 100% no teste em 1 ano. Na análise volumétrica, os valores encontrados foram 45,34% de preenchimento ósseo da fissura no grupo controle aos 6 meses e 40,63% no teste, 53,33% no controle e 53,1% no teste em 1 ano. Não houve diferença estatisticamente significante. Conclusão: A rhBMP-2 em membrana reabsorvível de colágeno produziu resultados semelhantes ao enxerto autógeno de medula de crista ilíaca ao reparar defeitos alveolares de fissuras labiopalatinas completas. / Objective: The purpose of this study is to assess the bony regeneration of alveolar clefts using bone morphogenetic protein (rhBMP-2) in a collagen sponge carrier. Material and Methods: Twenty four patients with unilateral complete cleft lip and palate, in the very best moment, were randomly assigned to groups control (iliac crest cancellous bone) and test (rhBMP-2 in an absorbable collagen sponge). They were evaluated 6 months and 1 year postoperative with periapical radiographs and computed tomographs using Chelsea scale. Results: For control group, radiographic examination revealed success index for bone height 81,82% 6 months and 83,33% 1 year postoperative; for test group, findings were 91,67% first control and 100% 1 year. Computed tomograph revealed 70% 6 months and 75% 1 year for control group, 91,67% first control and 100% 1 year for bone height test group. Volume ratios were 45,34% bone filling 6 months and 53,33% 1 year for control group and 40,63% 6 months and 53,1% 1 year for test. There was no statistical significance. Conclusion: rhBMP-2 in a collagen sponge carrier induced bony regeneration close to that from iliac crest cancellous bone to repair complete alveolar clefts.

OBJETIVO: Determinar a efetividade de manobras padronizadas de drenagem linfática manual (DLM) na redução do edema facial, na distância interincisal máxima ativa e no quadro álgico de pacientes submetidos à cirurgia de Enxerto Ósseo Alveolar (EOA). METODOLOGIA: Esta pesquisa analisou 51 indivíduos com fissura labiopalatina reparada, entre 10 e 15 anos de idade, submetidos ao EOA no Hospital de Reabilitação de Anomalias Craniofaciais-USP, divididos em 2 grupos, grupo tratamento (n=29, 12 homens e 17 mulheres) e grupo rotina (n= 22, 15 homens e 7 mulheres). No grupo tratamento foram aplicadas manobras de DLM padronizadas diferentemente daqueles do grupo rotina. Foram realizadas nos dois grupos avaliações do edema facial por meio das medidas da linha 1 (distância da base da asa nasal ao tragus) e linha 2 (distância da base da asa nasal à implantação inferior do pavilhão auricular), na hemiface operada nos períodos pré-operatório (Pré), segundo (2ºPO) e quarto pós-operatório (4ºPO). Também foram realizadas as medidas da distância interincisal máxima ativa nos mesmos períodos. A Escala Analógica da Dor (EAD) foi aplicada no 1º, 2º, 3º e 4º períodos pós-operatórios. Adicionalmente, no grupo tratamento, após a terapia de DLM, foram realizadas perguntas sobre dor, relaxamento e sono. RESULTADOS: Houve redução do edema facial no grupo tratamento do 2ºPO para o 4ºPO o que não ocorreu no grupo rotina. As medidas da distância interincisal apresentaram aumento entre o 2ºPO e 4ºPO nos dois grupos estudados. Na avaliação da EAD, o grupo tratamento mostrou ausência de dor no 3ºPO enquanto o grupo rotina somente no 4ºPO. No grupo tratamento, a totalidade dos indivíduos relataram que a dor diminuiu, e que se sentiram mais relaxados após a DLM, nos 3 períodos avaliados. Relataram também em muitos casos que a DLM teve efeito facilitador na indução ao sono durante a DLM. CONCLUSÕES: As manobras padronizadas de DLM aplicadas da maneira proposta produziram redução significante do edema facial, aumento da distância interincisal máxima ativa, redução do quadro álgico no grupo tratamento comparativamente ao grupo rotina. Esses dados reforçam a hipótese de que a DLM proposta foi efetiva contribuindo de maneira importante na recuperação do paciente submetido à cirurgia de EOA. / OBJECTIVE: To determine the effectiveness of standardized manual lymphatic drainage (MLD) maneuvers in reducing facial swelling, maximum interincisal active distance and pain of patients undergoing surgery for Alveolar Bone Grafting (ABG). METHODS: This study examined 51 individuals with repaired cleft lip and palate, aged 10 to 15 years old, who underwent ABG at the Hospital for Rehabilitation of Craniofacial Anomalies- USP, divided into two groups: treatment group (n = 29, 12 men and 17 women) and routine group (n = 22, 15 men and 7 women). In the treatment group MLD standardized maneuvers were performed differently from those of the group routine. In both groups evaluation of facial swelling was performed by measuring the distance from the ala nasi to the tragus (line 1) and the distance from the ala nasi to the inferior portion of the ear auricle (line 2), in the operated side, preoperatively, and at the second and the fourth postoperative (PO) day. The maximum active interincisal distance was measured during the same periods. The Pain Analog Scale (PAS) was applied at the first, second, third and fourth days after ABG. Additionally, patients from the treatment group, were asked about pain, relaxation and sleep after MLD therapy. RESULTS: There was a reduction of facial edema in the treatment group from the 2nd to 4th PO what was not observed the routine group. Interincisal distance increased between the 2nd and 4th PO in both groups. PAS evaluation has shown that patients from the treatment group present no pain already at 3rd PO. In the routine group this occurred only at 4th PO. All the subjects from treatment group reported decrease of pain, and patients reported felt more relaxed after the MLD, at the three postoperative evaluated. Many patients reported that MLD had a facilitative effect on inducing sleep during MLD. CONCLUSIONS: The standardized MLD maneuvers applied in the proposed manner produced significant reduction of facial swelling, increase of the maximum active interincisal distance, reduction of the pain in the treatment group as compared to the routine group.These Abstract data reinforce the hypothesis that the proposed MLD is a effective procedure for the recovery of the patients undergoing ABG surgery.

Background. The treatment of patients born with cleft lip and palate has been gradually modified over the years as the surgical procedures have developed and improved. Multidisciplinary team care has evolved and provided improved care with enhanced results. Clefts in the alveolus can be reconstructed by alveolar bone grafting or by periosteoplasty. The main goal is to repair and close the alveolar cleft and create a continuous alveolar processes so that the teeth can erupt. Aims. This thesis has several aims: to investigate the impact of dental status and initial cleft width on the outcome of Secondary alveolar bone grafting (SABG) in patients born with unilateral cleft lip and palate (UCLP) at the 10-year follow-up (Studies I and II); to compare the outcomes of primary periosteoplasty (PPP) with those of SABG in patients born with unilateral cleft lip and alveolus (CLA) (Study III); to evaluate clinical and radiographic conditions and identify factors important for the final treatment outcomes after SABG ( Study IV); to evaluate two radiographic methods, i.e. occlusal radiographs and cone beam tomography (CBCT)) for assessing alveolar bone height ( study IV). Results. In UCLP patients, SABG achieved excellent results in terms of bone height; tended to reduce with time, correlated with dental status and dental restoration factors. Occlusal radiographs correspond well with the CBCT, for evaluating alveolar bone height in cleft area. The width of the initial cleft does not seem to affect the success of SABG. Finally, patients with CLA treated with PPP at the time of lip repair have inferior bone formation outcomes in the cleft area compared with patients treated with SABG at the time of mixed dentition. Conclusion.  Poor dental status and malpositioning negatively affect the long-term survival of bone in the alveolar cleft. The initial cleft width affects certain dental status factors. In adults with UCLP, the alveolar bone height in the cleft was correlated to the presence of gingival inflammation and restorations at 20 years follow-up. Specially designed maintenance therapy is beneficial, after complex dental restorations in the cleft area. SABG is preferred to PPP for the reconstruction of alveolar clefts.

Introduction: The reconstruction of the alveolar cleft is a step of great importance in the treatment of patients with lip and palate cleft. This phase of treatment corrects oral-nasal communication, improves phonation, prevents maxillary arch collapse, improves periodontal condition of adjacent teeth, and promotes bone support for non-erupted canine eruption. Objective: To evaluate the reconstruction of the alveolar bone with the bone graft and to compare the outcomes of two different bone graft materials: autogenous bone grafts from mandibular symphysis and lyophilized bone grafts associated with platelet-rich plasma (PRP) for the reconstruction of alveolar cleft. Methods: Forty five individuals met the inclusion criteria and accepted to participate in the case series study. Patients were evaluated for area and volume reduction and were then divided into two groups. Group A patients underwent alveolar bone grafting using autologous bone graft and group B patients using bovine bone graft associated with PRP. Cone beam computed tomography scans were taken, and reconstructed three-dimensionally for all patients preoperatively and 1 year postoperatively. Results: A significant reduction was detected for area and volume in all patients, within the group A and the group B. Between groups, no significant difference was found for area or volume. Conclusion: Lyophilized grafts associated with PRP are a good option for the reconstruction of alveolar clefts, and provide good results such as autologous bone grafts. / Introdução: A reconstrução da fenda alveolar é uma etapa de grande importância no tratamento dos pacientes portadores de fissura lábio-palatal. Esta fase do tratamento corrige a comunicação buco-nasal, melhora a fonação, previne o colapso do arco maxilar, melhora a condição periodontal dos dentes adjacentes e promove suporte ósseo para erupção do canino não irrompido. Objetivos: Avaliar a reconstrução do osso alveolar com a enxertia óssea e comparar os resultados de dois diferentes grupos de materiais de enxerto ósseo: osso autógeno da sínfise mandibular e osso liofilizado associado ao plasma rico em plaquetas (PRP) na reconstrução de fendas alveolares. Métodos: Quarenta e cinco indivíduos foram incluídos nos critérios estabelecidos e aceitaram participar deste estudo de série de casos. Os pacientes foram avaliados quanto a redução da área e volume, posteriormente foram divididos em dois grupos. Grupo A pacientes que receberam enxerto ósseo autógeno da sínfise mandibular na fenda alveolar e o Grupo B pacientes que receberam osso liofilizado associado ao PRP. Tomografia computadorizada tipo cone beam foram realizadas e reconstruídas tridimensionalmente em todos os pacientes no pré-operatório e no pós-operatório de 1 ano. Resultados: Uma redução significativa foi encontrada na área e volume em todos os pacientes, no grupo A e no grupo B. Entre os grupos, não foram encontradas diferenças significantes na área e volume. Conclusão: Osso liofilizado associado ao PRP é uma boa opção para a reconstrução de fendas alveolares, e promove bons resultados assim como o osso autógeno. / Aracaju

Aim: The aim of this literature study was to systematically review the scientific evidence on the most effective donor sites and/or bone substitute material for secondary alveolar cleft grafting in alveolar cleft patients. Material and method: In order to acquire a systematic and transparent reporting this literature review was conducted according to the PRISMA statement. The literature search was performed in the following four databases; PubMed, CENTRAL, Web of Science and Scopus.The quality of the included studies was assessed using the revised Cochrane Risk of Bias 2 tool (RoB 2 tool). Result: The search identified 4754 studies. Five RCT studies was included in this systematic review and assessed different donor site or bone substitute materials. Two studies showed low risk of bias and three moderate risk of bias. Only one study showed a statistically significant difference when comparing iliac bone to substitute material however all studies presented substitute materials with satisfactory results. Conclusion: According to the data from this systematic review no clear conclusion can be drawn regarding what the most effective bone donor site and/or tissue engineered bone substitute material to use in secondary bone grafts. Based on the available evidence iliac bone could still be regarded as a benchmark, but more research and RCT’s of high quality are required, especially for artificial bone substitute materials. / Syfte: Syftet med denna litteraturstudie var att systematiskt granska den vetenskapliga evidensen gällande det mest effektiva bentagningsstället och/eller bensubstitutmaterialet vid sekundär bentransplantation hos patienter med käkspalt. Material och metod: För att uppnå en systematisk och transparent rapportering av denna litteraturstudie följdes PRISMA statement. Litteratursökningen gjordes i följande fyra databaser; PubMed, CENTRAL, Web of Science och Scopus. Kvaliteten av inkluderade studier granskades med hjälp av Cochrane Risk of Bias 2 tool (Rob 2 tool). Resultat: Sökningen identifierade 4754 studier. Fem RCT studier inkluderades i denna systematiska översikt vilka värderade olika bentagningsställen eller bensubstitut. Två studier bedömdes ha låg risk för bias och tre artiklar måttlig risk för bias. Endast en studie visade på en statistiskt signifikant skillnad vid jämförelse av höftben med bensubstitut däremot presenterade samtliga studier substitutmaterial med tillfredsställande resultat. Konklusion: Denna systematiska översikt visade att ingen klar slutsats kan dras gällande vilken det mest effektiva bentagningsstället eller bensubstitutsmaterialet är för sekundär bentransplantation hos patienter med käkspalt. Baserat på tillgänglig evidens kan transplantat från höftbenet fortfarande anses vara bäst lämpat men mer forskning samt RCT studier av hög kvalité erfordras, särskilt för artificiella bensubstitutmaterial.