Secondary bone grafting of alveolar clefts: a review of outcome at two centres in Australia and the UK

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Abstract

Secondary alveolar bone grafting is a key procedure in comprehensive cleft services, the main objective of which is to allow the canine to erupt through the bone. We have assessed the outcomes of the procedure at two units, one in Australia and one in the UK. Success was measured using standardised indexes for radiological assessment (Bergland and Kindelan) and clinically by noting eruption of canines through the grafted sites. The two-year review indicated that the two units had comparably high success rates. Canines erupted through cleft sites in 27/28 sites in patients in the UK, and 26/28 in patients in Australia, and the radiological success using the indexes was also high. These rates are in line with international benchmarks.

Introduction

Patients with cleft lip and palate also have a cleft in the tooth-bearing alveolar region that is managed by secondary alveolar bone grafting in most centres. The technique was successfully introduced by Boyne and Sands,1 and one of its key objectives is to enable the eruption of the permanent canine through the cleft site with sufficient periodontal and bony support.2

In 1998 the United Kingdom initiated an examination of cleft services by the Clinical Standards Advisory Group (CSAG),3 which made a thorough review of the outcomes of cleft lip and palate services. The outcomes of secondary bone grafting showed that only just over half the grafts done for 12-year-old children in the sample were deemed to be successful.3 This was considered unsatisfactory when compared with the benchmark of success set at 96% by a Norwegian Centre.2 This, together with other studies of the outcome of cleft surgery, led to the centralisation of cleft services in the UK. As a result, Alder Hey Children’s Hospital was designated as one of the sites, together with Manchester Children’s Hospital in the North West of England, and the Isle of Man and North Wales Cleft Lip and Palate Network.

In Australia, the Royal Children’s Hospital in Melbourne is one of the major centres for comprehensive cleft care, and outcomes of secondary alveolar bone grafting from this unit were reported in 2003.4

Our main aim in this review was to assess the outcomes of secondary alveolar bone grafting during the same two-year period at Alder Hey and Melbourne, two international cleft centres.

Section snippets

Methods

Ethics approval was obtained from both hospitals, and a retrospective, cross-sectional, review protocol was established. One investigator was designated to assess the sample of patients in each centre. Patients who had secondary alveolar bone grafting between 1 January 2004 and 31 December 2005 were identified and their clinical notes and radiographs reviewed and analysed. Patients with inadequate records were excluded.

A pro forma was used to record standard data that included the patient’s

Results

At Alder Hey 34 patients had grafts during the two-year period, and 28 of them who had adequate records were included in the audit. Five were excluded because of incomplete radiographs and one because of incomplete notes. Thirty-two cleft sites were grafted. At Melbourne 42 patients had grafts and the same number of patients (n = 28) with 32 sites were included. Eleven patients were excluded because of incomplete radiographs, and three had moved and had no follow up records. Other demographic

Discussion

We evaluated the success of secondary alveolar bone grafting at both centres. The clinical measure of canine eruption in 27/28 and 26/28 sites, respectively, provides a benchmark for other centres to follow. In addition,the Kindelan index of bony “in-fill” was rated at 30/32 at both institutions. This is comparable to the international gold standard.2 Both centres had much better results than the reported rate in a study carried out in Scotland which reported a success rate of 76% during a

Conclusions

This two-year review has shown that the two units had comparable success judged by both clinical and radiological criteria. The mean age at operation was between 10-11 years, which is within the recommended age group. Both centres are providing a quality service, which is in line with internationally recognised and recommended standards.

Conflict of interest

We have no conflicts of interest.

Ethics statement/confirmation of patients’ permission

Ethics approval was obtained from both hospitals. Permission was obtained from all patients’ parents or guardians.

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© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.