Risk factor analysis of bone resorption following secondary alveolar bone grafting using three-dimensional computed tomography

doi:10.1016/j.bjps.2015.11.002

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 69, Issue 4, April 2016, Pages 487-492

https://doi.org/10.1016/j.bjps.2015.11.002 Get rights and content

Summary

Background/Aim

The purpose of this study is to analyze the risk factors for bone resorption following secondary bone grafting in the alveolar cleft, using three-dimensional (3D) computed tomography (CT) based on surgical simulation software (SimPlant OMS, Materialise Dental, Leuven, Belgium).

Methods

We reviewed the secondary alveolar bone grafts performed by a single surgeon between January 2005 and January 2014. A total of 40 patients with unilateral alveolar cleft were included in this study. The grafted alveolar bone was measured using surgical simulation software. In order to validate the measurement, each data set was measured by three different analysts and the inter- and intraobserver variabilities were calculated. A total of eight risk factors for grafted bone survival, including patient age, sex, body mass index (BMI), palatal fistula, amount of grafted bone, dental appliance, canine or incisor eruption, and preoperative upper respiratory tract infection, were evaluated using the linear mixed model and Mann–Whitney test.

Results

The average alveolar defect size was 4.98 cc and the average graft survival was 67.5%. The inter- and intraobserver variabilities of simulation software were 0.758 and 0.915, respectively. Among the risk factors, only dental appliance (p = 0.02) and canine eruption (p = 0.041) were significantly correlated with graft survival. Other risk factors, including the amount of grafted bone, did not show a significant relationship with graft survival.

Conclusion

Measurement of an alveolar bone defect using a simulation program based on 3D CT is reliable and reproducible. Secondary bone grafting survival was significantly correlated with canine eruption and dental appliance in the alveolar cleft.

Introduction

Radiographic imaging is frequently used for the diagnostic evaluation and treatment planning of patients requiring alveolar bone grafts. However, conventional radiographic imaging, such as occlusal or dental periapical radiographs, have the disadvantage of attempting to derive three-dimensional (3D) information from a two-dimensional (2D) image.1, 2

Over the past few decades, computed tomography (CT) has been receiving increasing attention because of its precision and accuracy in locating anatomical structures and pathologic processes and visualizing maxillary and mandibular abnormalities.³ It has recently been identified as a useful clinical tool in the assessment of diagnosis and treatment of alveolar bone grafting.4, 5 Although axial CT scans provide much information, they emit a considerably higher dose of radiation to young patients. Therefore, cone beam CT has been proposed and used as an alternative, because of its low cost and lower radiation exposure.6, 7 Cone beam CT calculation of a simulated alveolar cleft and bone graft volume is also precise and accurate.⁶ Zhang et al. reported that 3D reconstruction based on cone beam CT is a promising method for evaluating the outcome of alveolar bone grafts and that bone grafts showed a high grade of resorption in patients lacking permanent tooth eruption.⁸

Several factors contribute to the success of secondary alveolar bone grafting. Sandy et al. reported that the younger the patient, the higher the rate of graft survival.⁹ Several studies have demonstrated that the success rate of bone grafts decreases if the procedure is performed after canine eruption on the cleft side.9, 10, 11, 12, 13, 14 Shuji et al. reported that the optimal time for surgery is when the canine cusp is close to the alveolar plane.¹⁴ Sex of the patient, type of cleft, and severity of the alveolar bone defect did not affect the success rate of secondary alveolar bone grafting.9, 15 However, there have been only few studies on the risk factors for secondary alveolar bone graft survival, which have no consensus.

To the best of our knowledge, this is the first study of its kind that analyzes the risk factors for bone resorption following secondary alveolar bone grafting using 3D reconstruction based on cone beam CT.

Section snippets

Method

A total of 40 secondary alveolar bone grafting cases were retrospectively reviewed between January 2005 and January 2014. The mean patient age was 9.15 years (range 6.7–12.8 years), and there were 16 female and 24 male patients. The inclusion criteria were unrepaired unilateral cleft, no previous history of alveolar bone grafting, and nonsyndromic children. Autogenous particulate cancellous bone was harvested from the anterior iliac crest with a minimal incision.

Results

In the axial, coronal, and sagittal slices, detailed information on the length, width, and depth of the bone transplant was provided. X, Y, and Z cursor lines represented the positions of the plane, and they could be moved using the computer mouse (Figure 1, Figure 2) The bone graft was easily differentiated from the surrounding tissue at 6 months, and a good maturation was observed with evidence of normal bone architecture. The maxilla and the position of an erupting canine relative to the

Discussion

It is difficult to accurately evaluate the morphology in the alveolar cleft region as the boundary of the bone must be identified visually. Although some studies have investigated landmarks that can be used as anatomical references,16, 17 to the best of our knowledge, no study has investigated such landmarks in imaging. We defined the anatomical boundaries of the alveolar cleft as the piriform margin superiorly, the amelocemental junction inferiorly, and the bony margins of the maxillary defect

Conclusion

Measurement of an alveolar bone defect using a simulation program based on 3D CT is reliable and reproducible. It will be a good option for estimating bone graft survival. Canine eruption and dental appliance increase the chance of secondary bone graft survival.

Disclosure

All authors have no conflict of interest.

Acknowledgments

None.

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Cited by (31)

Influence of osseous structure characteristics of unilateral alveolar cleft on outcomes of alveolar bone grafting: a retrospective study
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
To enhance the success rate of alveolar bone grafting, it is crucial to identify the factors that may influence the postoperative bone formation. This study aimed to investigate the impact of various osseous structure characteristics of alveolar clefts on the survival ratio of autogenous cancellous bone particle grafts.
A retrospective study was conducted on 60 patients who underwent surgery performed by the same surgeon between 2016 and 2022. Two researchers measured and recorded the bone defect volume (DV), postoperative bone formation volume at 1 year, contact area between the graft and the bone surface within the cleft (S), cleft width (CW), osseous occlusion relationships, and presence of a cleft palate and initial bone bridge within the cleft for each patient. Pearson correlation analysis, Spearman’s correlation analysis, and multiple linear regression analysis were performed.
The analysis results revealed statistical correlations between DV, CW, ratio of S to DV, cleft palate, initial bone bridge presence, and occlusion relationships with the survival rate. Multiple linear regression analysis showed that initial bone bridge and occlusion relationships affected the graft survival rate.
Based on the presence of initial bone bridges and occlusions, we can make a rough estimate of the postoperative bone formation outcome in patients. However, the underlying mechanisms by which these two factors influence the bone formation require further investigation. In addition, preoperative orthodontic treatment to improve occlusal relationships may improve the postoperative bone formation outcomes in alveolar bone grafting.
Effect of body mass index on progressive bone mineral density in patients with cleft after secondary alveolar bone grafting
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
Although childhood obesity matters, the association between body mass index (BMI) and bone mineral density (BMD) progression in grafted tissue after secondary alveolar bone grafting (ABG) for children with cleft alveolus is scarcely studied. Accordingly, this study explored the influence of BMI on BMD progression after ABG.
In total, 39 patients with cleft alveolus receiving ABG at the mixed dentition stage were enrolled. Patients were classified as underweight, normal weight, or overweight or obese according to age- and sex-adjusted BMI. BMD was measured in Hounsfield units (HU) from cone-beam computed tomography scans obtained 6 months (T1) and 2 years (T2) postoperatively. Adjusted BMD (HU_{grafted tissue}/HU_pogonion, BMD_a) was used for further analysis.
For underweight, normal-weight, and overweight or obese patients, BMD_aT1 values were 72.87%, 91.85%, and 92.89%, respectively (p = 0.727); BMD_aT2 values were 111.49%, 112.57%, and 113.10% (p = 0.828); and density enhancement rates were 29.24%, 24.61%, and 22.14% (p = 0.936). No significant correlation was observed between BMI and BMD_aT1, BMD_aT2, or density enhancement rates (p = 0.223, 0.156, and 0.972, respectively). For patients with BMI < 17 and ≥ 17 kg/m², BMD_aT1 values were 89.80% and 92.89%, respectively (p = 0.496); BMD_aT2 values were 111.49% and 113.10% (p = 0.216); and density enhancement rates were 23.06% and 26.39% (p = 0.573).
Patients with different BMI values had similar outcomes (BMD_aT1, BMD_aT2, or density enhancement rate) after our ABG procedure in the 2-year postoperative follow-up.
Comparison of 2- and 3-dimensional radiologic evaluation of secondary alveolar bone grafting of clefts: a systematic review
2020, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Citation Excerpt :
CT was obtained in all included studies, and 6 studies acquired additional 2-D radiographs, such as occlusal, periapical, or panoramic radiographs, postoperatively. Specifically, 2-D radiographs of 5 included studies were reconstructed from CT images; 3 studies27,29,30 reported that 2-D reconstructed images were evaluated separately from the 3-D reconstructions, with the examiners blinded to the 3-D reconstructions, whereas the other 2 studies31,32 did not make a clear statement. In 9 of the 11 studies, harvested bone was taken from the iliac crest, whereas the other 2 selected calvarial bone and monocortical mandibular bone, respectively.
Secondary alveolar bone grafting (SABG) has become the principal means of treating alveolar cleft defects. We reviewed the literature on 2-dimensional (2-D) and 3-dimensional (3-D) radiographic evaluation of SABG in patients with cleft lip and alveolus (CLA) and those with cleft lip and palate (CLP), with a focus on outcomes.
We searched several electronic databases to the end of 2018. The inclusion criteria were nonsyndromic CLA or CLP treated with SABG at an optimal age and evaluation performed no earlier than 3 months postoperatively. Study quality was evaluated by using the Methodological Index for Non-Randomized Studies and the Cochrane Collaboration tool.
We identified 282 articles from 3 databases. Full texts of 102 articles were analyzed, and finally 11 articles were included for qualitative analysis. 2-D and 3-D radiographic evaluations were performed in each study. Traditional 2-D radiographic imaging tended to overestimate success; bone resorption in the labiopalatal direction was inaccurate in 2-D views. Most articles were observational in nature and of moderate methodologic quality.
2-D evaluation tended to overestimate SABG outcomes; 3-D evaluation was more precise and reliable than 2-D radiography. A gold standard 3-D evaluation protocol is required for quantitative comparisons in the future.
Current methods for secondary alveolar bone grafting assessment in cleft lip and palate patients — A systematic review
2019, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Another two assessed results by means of height, thickness, and nasal floor height scores. The scale used by Oh et al. met the exclusion criteria (Oh et al., 2016). Han et al. used Enemark grading system to categorize results obtained for cleft/noncleft height and thickness ratios (Han et al., 2017).
The development of 3D X-ray diagnostics has led to new methods for secondary alveolar bone grafting (SABG) assessment. The aim of this study was to collect and present literature from the years 2007–2018, and review on the current treatment outcome assessment methods for SABG.
A systematic review of literature from 2007 to 2018 was carried out, following PRISMA guidelines. 426 records were identified after duplicate references had been removed. 25 articles were included in the review. The Cochrane Collaboration tool or the methodological index for non-randomized studies was used for quality evaluation.
Computed tomography and cone beam computed tomography were preferentially used for SABG treatment outcome verification. There were different assessment protocols. Due to the ways in which results were presented, methods were divided into five groups: linear measurements, volumetric measurements, density measurements, percentage ratios, and scales. There was only one randomized, controlled trial with high methodological quality.
1. Currently, 3D X-ray imaging is a standard treatment outcome verification method for SABG. 2. It is necessary to establish the required postoperative follow-up time for best SABG treatment outcome assessment. More prospective studies to assess bone graft outcomes after 6 months and 1 year are required.
Analyzing the teeth next to the alveolar cleft: Examination and treatment proposal prior to bone grafting based on three-dimensional versus two-dimensional diagnosis—A diagnostic study
2017, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Although in 47.3%–74.3% of cases the parameters “cleft type,” “border of the cleft” and “visibility of roots” were rated the same using 2D or 3D material, 39.0%–60.6% of the ratings using 3D images appeared to be superior to those using 2D images, as the examiners rated the borders of the cleft and/or the roots of the teeth as “clearly seen” in 3D but as “unclear” in 2D. As borders of cleft and of tooth-roots as well as the exact size of the alveolar defect (Hamada et al., 2005; Kapila and Nervina, 2015; Oh et al., 2016) are important for planning the surgical intervention, one can say that a CBCT scan prior to the procedure of bone grafting is a good choice from a surgical point of view. Exact knowledge of the cleft borders is important for estimating the required amount of bone to be transplanted.
The objective was to evaluate the diagnostic and prognostic value of three-dimensional (3D) cone beam computed tomography (CBCT) on information about the cleft and alignment of cleft neighboring teeth.
Panoramic X-rays, small-volume CBCTs, and study casts of 20 patients with a total of 22 alveolar clefts were analyzed prior to secondary bone grafting. Six maxillofacial surgeons and 6 orthodontists rated the following parameters: visibility of alveolar cleft expansion, position and probability of alignment of cleft neighbored teeth. Two-dimensional (2D) X-rays and casts were rated first; CBCT and casts followed at least 4 weeks later. Radiologic bone height in the region of the former alveolar cleft, as well as alignment and reasons for nonalignment of cleft neighbored teeth, were recorded 4 years later.
The rate of proper proposals regarding the real treatment outcome using 2D- or 3D-material did not differ statistically. Although 5%–45% of the proposals were changed when using 3D instead of 2D records, Fleiss multirater kappas showed no essential differences. Raters' profession and experience had no influence on the rate of correct proposals.
In orthodontics, small-volume CBCT may be justified only as supplement to a routine panoramic X-ray, and only in selected cases or for surgical preparation.
Extracorporeal Shockwave Therapy Improves Outcomes Following Secondary Alveolar Bone Grafting
2023, Face

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Risk factor analysis of bone resorption following secondary alveolar bone grafting using three-dimensional computed tomography

Summary

Background/Aim

Methods

Results

Conclusion

Introduction

Section snippets

Method

Results

Discussion

Conclusion

Disclosure

Acknowledgments

Am J Orthod

J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol Oral Radiol

Am J Orthod

Am J Orthod Dentofac Orthop

Am J Orthod Dentofac Orthop

J Craniomaxillofac Surg

Br J Oral Maxillofac Surg

J Maxillofac Surg

J Craniomaxillofac Surg

Cleft width and secondary alveolar bone graft success

Cleft Palate Craniofac J

Enhancing implant surgery planning via computerized image processing

Int J Comput Dent

Alveolar cleft bone grafts: results and imprecisions of the dental radiograph

Plast Reconstr Surg