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American Association of Plastic Surgeons
28. Arch Form, Facial Growth and Requirement for Secondary Procedures in Patients with Complete Cleft Lip and Palate After Primary Alveolar Bone Grafting
John A. van Aalst, MD, MA1, Ronald R. Hathaway, DMD2, Barry L. Eppley, DMD, MD2, Robert J. Havlik, MD2, A. Michael Sadove, MD2.
1University of North Carolina, Chapel Hill, Chapel Hill, NC, USA, 2Indiana University, Indianapolis, IN, USA.

PURPOSE: The most significant advance in the management of the alveolar cleft is bone grafting of the alveolus. Controversy however, exists about timing of the bone graft. Primary alveolar bone grafting (PABG) --preformed before eruption of the deciduous canine--has been practiced at our institution since 1982. We have previously reported on PABG patients at mixed dentition and now report on patients after skeletal maturity.
METHODS: A retrospective review identified 264 patients with nonsyndromic complete cleft lip and palate (CL/P) eligible for PABG between 1982 and 1992; all are currently older than 12 years of age. There were 189 patients with unilateral CL/P (133 with PABG and 56 controls) and 75 patients with bilateral CL/P (51 with PABG and 24 controls). Demographic parameters included gender, dates of all primary surgeries, secondary alveolar bone grafting (SABG), surgery for palatal fistulas and velopharyngeal insufficiencey, orthodontic and orthognathic treatment. All patients were invited for follow-up; those who responded underwent lateral cephalograms, occlusal films and impressions for dental casts. There were 89 patients who agreed to follow-up: 58 with unilateral CL/P (44 with PABG and 14 controls), 31 with bilateral CL/P (23 with PABG and 8 controls). Lateral cephalogram measurements included SNA, SNB, ANB, NAP, NS-MP, N-ANS, Me-ANS, ANS-PNS, and Go-Me. Cast measurements included four maxillary (MxArL, Mx3to3, Mx5to5, Mx6to6) and four mandibular measurements (MnArL, Mn3to3, Mn5to5, Mn6to6).
RESULTS: Unilateral PABG patients required SABG in 33% of cases compared to 83% of unilateral controls (p<.001); 22% of unilateral PABG patients required fistula repair, while 34.5% of controls required repair (p=.076); requirement for orthodontic and orthognathic treatments were identical. Bilateral PABG patients required SABG in 38% of cases while 95.8% of controls required SABG (p<.001). Orthodontic treatment was required by 60% of bilateral PABG patients and 86.4% of controls (p=.052). Fistula repair and need for orthognathic treatment were similar in both groups. Unilateral CL/P patients with PABG had mean values of 75.3 degrees (SNA), 75.7 degrees (SNB) and -.31 (ANB) which were not significantly different from control values. The values for ANS-PNS/Go-Me, ANS-PNS and N-ANS/Me-ANS were higher for PABG patients than controls and approached statistical significance (p= .076 - .087). The value for N-ANS was 57.8 mm for PABG and 53.6 mm for control patients (p=.014). Bilateral PABG patients and controls showed no statistical differences in any values; however, values for SNA (76 degrees for PABG patients; 74.9 degrees for controls) and SNB (75.8 degrees for PABG and 72.9 degrees for controls) showed increased values in the patients who underwent PABG. There were no statistically significant differences in dental cast measurements between the PABG patients and controls.
CONCLUSION: PABG does not result in any statistically significant growth attenuation of the mid-face or compromise of arch form in complete unilateral or bilateral CL/P patients. The advantanges of PABG include significant reduction in need for subsequent SABG in both unilateral and bilateral CL/P patients. PABG also reduces the need for subsequent fistula repair in unilateral patients and the need for orthodontic treatment in bilateral patients.


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