ORIGINAL ARTICLE

Long-term stability of alveolar bone grafts

in cleft palate patients
Dominique Toscano,a Ugo Baciliero,b Antonio Gracco,c and Giuseppe Sicilianid
Ferrara, Vicenza, and Padova, Italy

Introduction: Many authors have examined the surgical bone treatment of cleft palate patients, but no study has
emphasized the role of orthodontic therapy. The aims of this study were to evaluate the long-term stability of bone
grafts when using an orthodontic-surgical protocol, to determine the success of bone grafts in minor vs severe
clefts, and to develop a qualitative method for assessing the success of bone grafting. Methods: Forty-nine pa-
tients were included in this study. Occlusal x-rays were taken before (T0), immediately after (T1), and at least 1
year after bone grafting (T2). Two radiographic parameters were analyzed adjacent to the cleft side: the vertical
bone level (Bergland scale) and the horizontal bone level (Witherow-derived scale). Results: The bone graft
success at T2 was 91.84% (95% confidence interval, 84.55-96.41). The severity of the cleft before grafting
was not statistically correlated with success at T2 (P \0.05). The concordance rate between Bergland and With-
erow values was 87.07% (95% confidence interval, 82.69-90.69). The variables analyzed (sex, age, type of cleft,
lateral incisor agenesis) were not statistically correlated (P \0.05) with the stability of bone graft. Based on the
results, the only factor involved in the stability of the graft seems to be dental age at the time of bone grafting and
the orthodontic therapy before and after grafting. Conclusions: It seems appropriate to recommend early appli-
cation of a surgical-orthodontic protocol to treat cleft lip and palate patients, prevent postoperative bone
resorption, and guarantee correct positioning of the teeth. (Am J Orthod Dentofacial Orthop 2012;142:289-99)

M
any studies have examined the surgical bone
treatment of cleft palate patients; however,
only a small number of these have addressed
the long-term stability of the alveolar grafts.1-20
There is a consensus among academic oral surgeons
regarding the necessity of postponing bone grafting un-
til the mixed dentition and then using a technique called
“secondary bone grafting.”1-16 Boyne and Sands15,16
distinguished an “early” secondary bone grafting,
usually performed between the ages of 2 and 5, and
a “late” secondary bone grafting, usually after 5 years
of age. This surgical technique has many advantages,
including unified maxillary reconstruction and
continuous alveolar formation, physiologic eruption of
the teeth adjacent to the cleft, stabilization of cleft
a
Postgraduate student, School of Orthodontics, University of Ferrara, Ferrara,
Italy.
b
Director, Department of Maxillofacial Surgery, Regional Hospital of Vicenza,
Vicenza, Italy.
c
Assistant professor, School of Dentistry, University of Padova, Padova, Italy.
d
Chairman, Postgraduate School of Orthodontics, University of Ferrara, Ferrara,
Italy.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Dominique Toscano, via Montebello, n. 31, 44100, Ferrara,
Italy; e-mail, dominique_toscano@hotmail.it.
Submitted, July 2011; revised and accepted, April 2012.
0889-5406/$36.00
Copyright ! 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2012.04.015
fragments, opportunity for a rapid expansion of the
midline suture, elimination of oronasal fistulas, and
overall facial esthetic improvements.17 However, all sur-
gical and grafting procedures can cause growth
alterations with bone dysplasias that are more severe
when the procedure is performed early.18,19 For this
reason, Kuijpers-Jagtman and Long5 concluded that
a critical and customized case assessment is necessary
to determine the risks and benefits of the procedure.
Despite the many studies on the outcomes after
secondary bone grafting, they have significant limita-
tions, including reported success rates of less than
100%, small sample sizes, inconsistent inclusion and
exclusion criteria, incomplete and heterogeneous clini-
cal records, limited follow-ups, and subjective methods
for assessing the success of bone grafts.17,20-26
Many factors are involved in the success of alveolar
bone grafting. The first important factor is the canine
position and its eruption stage at the time of bone graft-
ing. Several studies have demonstrated that the success
of bone grafts decreases if the procedure is performed
after canine eruption on the cleft side.21,23,25,27 The
second fundamental factor is the role of the therapy
protocol and the orthodontic role, which have not
been explored in the literature.
The aims of this study were to evaluate the long-term
stability of bone grafts with an orthodontic-surgical
289
290
protocol, to determine the success rate of bone grafts in
minor vs severe clefts, and to develop a qualitative
method for assessing the success of bone grafting.
MATERIAL AND METHODS
In this retrospective clinical trial, we analyzed the
records of 446 complete cleft lip and palate patients,
recruited from the Regional Hospital of Vicenza (Italy),
Cleft Palate Patients National Reference Centre, between
1994 and 2011. There was only 1 data manager (D.T.),
and all records were digitized. The study population
consisted of white patients matched for sex and age.
Patients were included in the study based on the
following criteria: (1) congenital complete cleft lip and
palate; (2) treatment with the protocol of the Regional
Hospital of Vicenza and the University of Ferrara; (3)
digital occlusal radiographs before (T0), immediately af-
ter (T1), and at least 1 year after bone grafting (T2); (4)
performance of the alveolar bone graft by the same sur-
geon; (5) digital occlusal x-rays exposed with a standard-
ized radiologic technique (long-cone technique and root
direction perpendicular to the palatine midline, com-
pared with 2 other projections, to prevent radiologic su-
perimpositions, image artefacts, and interpretation
errors) by the same radiologist; (6) standardized radio-
graphic evaluations; and (7) informed consent from
each patient. Patients were excluded if they had syn-
dromic cleft lip and palate. A total of 117 patients
met all inclusion criteria. The study was double-
blinded, and the statistical analysis was performed by
an external statistician. Of the 117 patients who met
the inclusion criteria, 68 were excluded for various rea-
sons, leaving 49 patients in the study cohort (Table I).
A flow chart of the study participants is shown in the
Figure. Table II gives the sex distribution. There were
45 unilateral and 4 bilateral clefts. Among the 45 pa-
tients with unilateral clefts, 15 were right sided, and
30 were left sided. Thirty-two patients demonstrated lat-
eral incisor agenesis, and 8 patients had agenesis of
other teeth, contralateral to their clefts.
All patients had a surgical-orthodontic protocol in
accordance with the Regional Hospital of Vicenza
and the Postgraduate School of Orthodontics at the
University of Ferrara in Italy. The chronologic order of
the treatment, according to the protocol, is outlined
below.
1. At birth: placement of a passive palate plate, con-
structed of soft resin.
2. At 3 months of age: soft-palate surgery28-30 and
lip and nostril surgery31 with definitive lip repair.
3. At 6 months of age: unilateral and bilateral rhino-
plasty.32
September 2012 ! Vol 142 ! Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Toscano et al
Table I. Patients excluded from the study
Patients (n)
Impossible to find radiographs 5
Preoperative radiographs not exposed 10
Postoperative radiographs not exposed 22
Bone graft unnecessary 8
Bone graft not currently performed 5
Digital radiographs not exposed 18
Patients excluded from study 68
4. At 8 to 12 months of age: initiation of speech
therapy.
5. At 18 to 20 months of age: hard palate surgery30
and continuation of speech therapy.
6. At 5 years of age: placement of a hyrax-type rapid
palatal expander bonded onto the deciduous teeth,
with palatal and buccal arms reaching to the canines,
activated at a quarter turn per day. The average
activation period depended on the degree of maxil-
lary constriction. A 2- to 3-mm overcorrection at the
molars was recommended to counteract relapse.
Immediately after the expansion, a maxillary trac-
tion device (Delaire mask) was applied with 450 g
of force per side for 14 hours per day for 7 months.
The rapid palatal expander was passively maintained
in the mouth for 1 year after the expansion.
7. At 6 to 9 years of age: placement of a passive trans-
palatal bar (0.036-in wire) bonded onto the first
permanent molars (to prevent transverse relapse)
and continuation of speech therapy.
8. At 9 to 11 years of age: placement of an alveolar
graft in the cleft side, using bone from the iliac
crest, once canine root development was between
one fourth and two thirds of its final root length as
identified on the occlusal x-ray.18,19,33
9. At 9 to 15 years of age: orthodontic fixed therapy
with preadjusted 0.022 3 0.028-in brackets to ob-
tain alignment, leveling, malocclusion correction,
and canine repositioning in the arch. Orthodontic
therapy began when canine root development
was between one fourth and two thirds of its final
root length. Orthodontic appliances were kept in
place through the transitional phase of the denti-
tion until all teeth had erupted and definitive ortho-
dontic treatment was completed, when all occlusal
and functional goals of therapy were achieved.
10. At 18 years of age: plastic (lip revision, nose revi-
sion, rhinoplasty, nasal septum surgery, adenoid
surgery, sinus mucous membrane surgery, scar
surgery) or maxillofacial surgery and implantation
if necessary. In this study, no patient received jaw
surgery, plastic surgery, or implantation.
Toscano et al 291

Assessed for eligibility (n=446)

Recruited from the Regional Hospital of Vicenza (Italy)
Cleft Palate Patients National Reference
Centre since 1994

Inclusion criteria Exclusion criteria

- Congenital complete cleft lip and palate - Syndromic cleft lip and palate
disease
- Surgical-orthodontic therapy protocol
(Vicenza-Ferrara)
- Digital occlusal X-rays at T0, T1, and T2
under standardized condition
- Same surgeon
- Same radiologist
- Standardized radiographic evaluations
- Patient informed consent

Enroll
Meeting inclusion Not meeting inclusion
criteria (n=117) criteria (n=329)

Follow-up

Lost to follow up (n=68)

Reasons: impossible to find X-rays, preoperative
and postoperative X-rays not exposed,
unnecessary bone graft, bone graft not currently
performed, digital X-rays not exposed

Analysis

Analyzed
(n=49)

Fig. Flow chart of the study participants.

Each patient had digital occlusal x-rays taken before
the alveolar bone graft surgery (T0). The radiographs
were taken using an AC Cefla dental machine with
a CEI OXC 070G x-ray tube (Anthos, Imola, Italy). The
machine was set at 65 kV and 7.5 mA. The focus-to-
skin distance was 20 cm. Exposure time varied
depending on the size of patient but was consistent
for preoperative and postoperative x-rays and varied
from 0.7, to 0.86, to 1.0 seconds. The film was oriented
parallel to the occlusal plane, and the central beam was
directed perpendicular to the cleft side for the first pro-
jection and at 70" to the film in the mesial and distal
directions for the second and third projections. Then
x-rays were processed with a dental vista scan machine
(model 2130-51; D€ urr Dental, Bietigheim-Bissingen,
Germany) with DBSWIN software (D€ urr Dental).
A numeric code was assigned to each patient before
the evaluations to ensure blinding of the reviewers.

American Journal of Orthodontics and Dentofacial Orthopedics September 2012 ! Vol 142 ! Issue 3
292
Table II. Sample distribution by sex
Sex n
Male 33
Female 16
At T0, qualitative categorizations of cleft severity
were made by using occlusal x-rays and based on the
amount of bone support on each root adjacent to the
cleft site. A standard for evaluation was adopted ac-
cording to 2 scales: the Bergland vertical bone evalua-
tion25 and the Witherow-derived horizontal bone
evaluation.34 These scales are shown in Table III (types
I, II, III, and IV and scores of 1, 0.5, and 0 were qual-
itative values used to indicate gradations in the pres-
ence or absence of bone). We compared each
radiograph with its corresponding 2 other projections
(the tube was directed at 70" to the film in the mesial
and distal directions) to prevent image artefacts and in-
terpretation errors. Two values were obtained for each
cleft. The first value was related to the distal surface of
the tooth on the mesial side of the cleft (site 1), and the
second represented the mesial side of the tooth on the
distal side of the cleft (site 2). In patients with bilateral
clefts, both clefts were evaluated; however, only 1
value was recorded in the table because of identical re-
sults.
All evaluations were performed by a blinded examiner
(D.T.) and repeated 3 times on 3 different days, with a 30-
day interval between evaluation sessions, to assess intra-
examiner variability. Twelve randomly selected patients
were assessed by 3 blinded and experienced examiners
(U.B., A.G., G.S.) to evaluate interexaminer variability.
Based on the results, the patients were divided into
the following groups (Table IV): (1) minor cleft: type I,
score 1 or 0.5, on both teeth adjacent to the cleft; (2)
moderate cleft: types II and III, score 0.5, on both teeth
adjacent to the cleft; and (3) severe cleft: type IV, score 0,
on both teeth adjacent to the cleft. Patients were also in-
cluded in the gravest group if there was a different value
on the roots adjacent to the cleft.
According to the protocol, an alveolar bone graft on
the cleft side and an immediate postsurgical occlusal
x-ray were performed on each patient. The patients
were then examined monthly to monitor the orthodontic
therapy. At T2, a long-term occlusal x-ray was obtained,
and a qualitative evaluation of bone level was performed
on the teeth adjacent to the cleft at T1 and T2. On 12
randomly selected patients, these evaluations were
made by the first examiner and the 3 other examiners
to evaluate interexaminer variability.
The first examiner obtained 294 values and repeated
each measurement 3 times. The other 3 examiners
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Toscano et al
Table III. Bergland scale and Witherow-derived grad-
ing system
Bergland scale
Type I Septal height approximately normal
Type II Septal height at least three quarters of normal
Type III Septal height less than three quarters of normal
Type IV Absence of a continuous bony bridge
Witherow-derived scale
Score 0 No bone from the root surface to the midline of the cleft
Score Some bone but fails to reach the midline
0.5
Score 1 Bone extends from the root surface to the midline
Table IV. Severity of cleft distribution before bone
grafting
Severity of cleft n
Minor 7
Moderate 30
Severe 12
Total 49
obtained 216 values, resulting in a total of 1098 evalu-
ations (Tables V and VI).
By using this method, both of the following criteria
had to be met for a successful outcome at T2: (1) vertical
and horizontal bone values equal to or better than the
bone values at T1; and (2) type I and score 1 (vertical
and horizontal bone levels approximately normal), with
bone support greater at T2 than at T0.
The patients’ records were reviewed for additional
biometric data. Particular attention was paid to type of
cleft (unilateral or bilateral); age at the 3 evaluation
times; sex; any supernumerary teeth, diminutive lateral
incisors, and peg-shaped lateral incisors in the cleft
area; any supernumerary or diminutive teeth not in the
cleft area; absence of any teeth adjacent to the cleft
and the probable cause thereof; and the incidence of re-
grafting.
The average age at the time of bone grafting was
10.25 years, with a range of 8 to 14.7 years (Table VII).
The average age at follow-up was 12.16 years, with
a range of 10.1 to 15.6 years. The average time of
follow-up after grafting was 1.87 years, with a range
of 1 to 4.8 years (Table VIII).
At T2, 38 patients (77.55%; 95% confidence interval
[CI], 63.38-88.23) had not experienced canine eruption,
and 11 patients (22.44%; 95% CI, 11.77-36.62) had ca-
nine impaction requiring a surgical flap and orthodontic
recovery.
Statistical analysis
The percentage of bone graft success was calculated
at T1 and T2. To evaluate whether the severity of the
Toscano et al 293

(2) The effects of type of cleft (unilateral or bilateral)

Table V. Sample distribution for Bergland grading
were assessed by using a binomial test (P \0.05). This
system (first operator's first evaluation)
determines the statistical significance of the deviations
I II III IV from the expected and the observed distributions into
T0 19 48 18 13 2 categories. (3) Lateral incisor agenesis was also as-
T1 96 2 0 0 sessed by using a binomial test (P \0.05). (4) Finally,
T2 97 1 0 0
we used the Wilcoxon signed rank test to determine
the surgical success rates (P \0.05). This is a nonpara-
Table VI. Sample distribution for Witherow-derived metric statistical hypothesis test used to assess whether
grading system (first operator's first evaluation) population means differ when comparing 2 related sam-
ples or repeated measurements of 1 sample. It is useful in
0 0.5 1 evaluations of ordinal-scale variables.
T0 13 85 0 The chi-square test (P \0.05) was used to verify the
T1 0 12 86
correlation between the severity of the cleft palate at T0
T2 0 8 90
and any lost teeth adjacent to the cleft at T2, and
whether site 1 had a different Bergland value than site
Table VII. Sample age at time of bone grafting 2 at any of the 3 measurement times. A binomial test
(P \0.05) was used to evaluate whether lateral incisor
Average age (y) SD n Minimum Maximum Median
agenesis at T0 was correlated with the spontaneous
10.25 1.21 49 8.00 14.70 10.00
eruption of the canines at T2, and whether there was
an association between the type of cleft at T0 and any
Table VIII. Follow-up time lost teeth adjacent to the cleft at T2.
The statistical analysis was performed with the R
Average (y) SD n Minimum Maximum Median 2.12 3 64 software (copyright 1998-2012 by Kurt
1.87 1.10 49 1.00 4.80 1.30 Hornik), and the statistical significance level was set at
95% (P \0.05).
defect was correlated to the success of bone grafting at
T2, the results were subjected to the nonparametric chi- RESULTS
square test. To evaluate whether the Bergland scale was
comparable with the Witherow-derived scale, the Ken- Success rate and grading systems
dall coefficient of concordance was used (0 \ Kendall The success rate at T1 was 70.41% (95% CI, 60.34-
W \1). The Kendall W expresses the level of agreement 79.21). The success rate at T2 was 91.84% (95% CI,
of multiple assessments from the same or different oper- 84.55-96.41). The binomial intervals of confidence did
ators. This coefficient is a real number between 0 (no not intersect; therefore, the T2 success rate was
agreement) and 1 (full agreement). A Kendall W less significantly greater than that at T1.
than 0.7 indicates little agreement and that the mea- The correlation between cleft palate severity and suc-
surement method can lead to inaccurate results, whereas cess rate at T2 was not statistically significant (P 5 0.64).
a Kendall W greater than 0.9 indicates strong agreement The Kendall coefficient of concordance was 0.99 for
and that the results are likely to be accurate. both the Bergland and the Witherow-derived scales (0 \
We calculated the Kendall coefficient of concordance Kendall W \ 1), indicating that these scales were com-
(0 \ Kendall W\ 1) to control for intraexaminer and in- parable.
terexaminer repeatability and reproducibility. It was acceptable to use the Kendall W because the
In addition, we evaluated several variables to deter- concordance rate between the Bergland and With-
mine whether they had statistically significant effects erow-derived values was 87.07% (95% CI, 82.69-
on the long-term stability of the bone grafts at T2. (1) 90.69), and the error method was not relevant.
The potential effects of sex and age (at bone grafting) Table IX shows the cross-tabulation of the Bergland
were analyzed by using a linear regression analysis, and Witherow-derived evaluations by first operator and
which is an approach to modeling the relationship be- first evaluation. It highlights the error point in which 37
tween a scalar variable Y and at least 1 variable called type I Bergland values were classified as a Witherow-
X. Proceeding to the statistical analysis, the patients derived score of 0.5.
were further divided into those who were 10 years or After the alveolar bone graft, there were no oronasal
younger and those older than 10 years, in accordance or palatal fistulae, and bone filling was radiographically
with sample medians equal to 10 years old (P \0.05). evident on occlusal x-rays.

American Journal of Orthodontics and Dentofacial Orthopedics September 2012 ! Vol 142 ! Issue 3
294
Table IX. Cross-tabulation of the first operator's first
evaluation
Type 0 0.5 1 I
I 0 37 175
II 0 50 1 Site 2 (n)
III 0 18 0
IV 13 0 0
In our 3 groups (minor, moderate, and severe clefts),
no regrafting was necessary.
Variables affecting the long-term stability
As previously mentioned, we determined the intra-
examiner variability by calculating the Kendall coeffi-
cient of concordance for the 3 series of values. The
coefficient was 0.98 for both Bergland and Witherow-
derived values (0\Kendall W\1), signifying a high de-
gree of repeatability. The interexaminer variability was
also determined by using the Kendall coefficient of con-
cordance for the 3 series of values. It was 0.99 for both
Bergland and Witherow-derived values (0 \ Kendall
W \1), signifying a high degree of reproducibility.
There was no statistically significant correlation
between the patient's sex or age and the success of the
alveolar bone graft at T2 (P 5 0.08 and P 5 0.94, re-
spectively).
There was no statistically significant influence of the
type of cleft (unilateral or bilateral) on the long-term
stability of the bone graft (P 5 0.84).
There was no statistically significant influence of lat-
eral incisor agenesis on the long-term stability of the
bone graft at T2 (P 5 0.32).
The Bergland vertical bone evaluation resulted in P 5
0 for T1 vs T0, and P 5 1 for T2 vs T1. The Witherow-
derived horizontal bone evaluation resulted in P 5 0 for
T1 vs T0 and P 5 0.13 for T0 vs T2. Based on the P values,
there was a statistically significant Bergland and With-
erow-derived value improvement only from T0 to T1.
Clinical features and bone graft
At T0, there was a statistically significant difference
between the Bergland bone levels observed at sites 1
and 2 (P 5 0), with site 2 having a greater bone level
than site 1, as shown in Table X.
At T1 and T2, there was no statistically significant
difference between Bergland bone levels at sites 1 and
2 (Bergland grading system with P 5 0.47).
Spontaneous canine eruption at T2 was not associ-
ated with lateral incisor agenesis (P 5 0.34) or cleft pal-
ate severity at T0 (P 5 0.77).
Teeth lost adjacent to the cleft at T2 did not correlate
with cleft palate severity (P 5 0.64) or type of cleft at T0
(P 5 1).
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Toscano et al
Table X. Sample distribution for sites 1 and 2 for the
Bergland bone level types
II III IV
Site 1 (n) 8 24 5 12
11 24 13 1
There were 12 patients (24.48%; 95% CI, 13.34-
38.87) with diminutive teeth outside the cleft area.
None had supernumerary teeth far from the cleft side.
DISCUSSION
The main purpose of this study was to evaluate the
long-term stability of alveolar bone grafts with an
orthodontic-surgical protocol. Our success rates were
70.41% (95% CI, 60.34-79.21) at T1 and 91.84%
(95% CI, 84.55-96.41) at T2; these correspond well
with results reported in the literature (90%, Bergland
et al25 in 378 patients; 83%, Amanat and Langdon35
in 34 patients; 91%, Long et al17 in 43 patients; 73%,
Kindelan et al36 in 38 patients; 72%, Da Silva Filho
et al37 in 50 patients; 91%, Lilja et al38 in 70 patients;
and 95%, Jia and Mars39 in 55 patients).17,25
We used the Kendall coefficient of concordance to
evaluate method error, intraobserver repeatability, and
interobserver reproducibility. The statistical analysis
indicated that the Kendall W value was close to 1, and
the method error was insignificant for the study. Fur-
thermore, there was 87.07% agreement between the
Bergland and the Witherow-derived values; therefore,
we can assume that this is a simple and accurate quali-
tative method for assessing the success of bone grafting.
Bergland et al25 evaluated the height of the interdental
bone ridge adjacent to the erupted canine on the cleft
side, using a qualitative scale and radiographs taken at
least 1 year after surgery. Long et al17 measured contours
of the grafted bone with a qualitative method from the
occlusal or periapical radiographs of 43 patients with 56
total cleft sites, taken at least 6 months after surgery.
The mean follow-up time was 3.1 years (range, 0.6-8.1
years). We focused on the bone adjacent to the cleft
side and measured its contours with 2 qualitative scales
to assess the bone in the vertical and horizontal directions.
On the occlusal radiographs of 49 patients at least 1 year
after bone graft surgery, 98 cleft sites were analyzed (2 per
subject). The mean follow-up time was 1.87 years (range,
1-4.8 years). Our follow-up was at least 1 year rather than
6 months after surgery, as reported by Long et al. This 1-
year interval after the bone graft was thought to allow for
adequate bone maturation to occur.25
Various studies have confirmed the reliability of qual-
itative measurements in occlusal and periapical x-rays
Toscano et al
for assessing the stability of bone grafts.17,25,34,40
However, no authors have used 2 scales at the same
cleft site and at the same time. Because of its high
repeatability and reproducibility, the latter method is
statistically more accurate. It also allows for a 2-
dimensional (vertical and horizontal) assessment of the
long-term success of bone grafts, exposing the patients
to a low dose of cerebral radiation, in accordance with
the radiation protection rules and the ethical, regulatory,
and scientific principles governing clinical research in the
Declaration of Helsinki (2004). Furthermore, this qualita-
tive method eliminates the measurement errors that
result from radiographic image distortions. The only er-
ror was on the minor cleft side, where some Bergland
type I values were classified as Witherow-derived scores
of 0.5.
In this study, the average age at bone grafting was
10.25 years, with a range of 8 to 14.7 years. This is sim-
ilar to the data reported by Paulin et al,41 Brattstr€
om and
McWilliam,42 and Long et al,17 thereby highlighting the
consensus about when to perform secondary bone
grafts.
The most important clinical finding in our study was
that cleft severity does not statistically correlate with the
rate of surgical success at T2. This finding is consistent
with the report of Long et al.17 Furthermore, regression
analysis showed a low correlation between the presurgi-
cal cleft width and the success of alveolar grafts. There-
fore, minor, moderate, and severe clefts appear to have
the same long-term stability.
Our study did not identify any clinically apparent
oronasal or palatal fistulae after surgery; this agrees
with the studies of Russell and McLeod43 and Long
et al,17 who reported only 1 patient with a residual oro-
nasal fistula.
In our 3 groups (minor, moderate, and severe clefts),
there was no regrafting; this is lower than any rate of
regrafting reported in the literature (less than 2% in
the studies of Hall and Posnick,22 Bergland et al,25 and
Long et al17). Helms et al26 reported a higher rate of
regrafting (19%) in both the secondary early and delayed
graft groups, probably due to the dental age of their pa-
tients at the time of bone grafting.
Another interesting observation was that linear
regression analysis demonstrated no statistically signifi-
cant correlation between the patient’s sex and age (at
bone grafting) and graft success at T2. Therefore, sex
and age did not influence the long-term stability of
bone grafts in our patients. Furthermore, there was no
significant correlation between type of cleft (unilateral
or bilateral) at T0 and the long-term stability of the
bone graft at T2. This indicates that the type of cleft
did not influence the success of bone grafts. We also
American Journal of Orthodontics and Dentofacial Orthopedics
295
did not find a significant influence of lateral incisor agen-
esis on the long-term stability of bone grafts at T2. This is
consistent with data from Russell and McLeod.43
Others factors that possibly contribute to the vari-
ability in graft success were excluded in this study
because of these factors: the same surgeon and the
same surgical technique were used, the same bone was
grafted (in contrast, Long et al17 used cancellous bone
from the iliac crest in 95% of patients and cranial
bone in 5% of patients), and the eruption stage of the
teeth in the distal cleft segment (canine) was identical
for all patients. We could also exclude variations due
to surgeon or surgical technique because we found a sta-
tistically significant improvement of Bergland and
Witherow-derived values from T0 to T1.
Another important clinical finding of our study is
that, at T0, there was a statistically significant difference
in the Bergland bone levels between site 1 (mesial side of
the cleft) and site 2 (distal side of the cleft). We found
that site 2 had a higher bone level than did site 1; this
is consistent with the findings of Teja et al44 and Long
et al.17 Both studies attributed this difference to the
eruption of the mesial tooth into an unfavorable posi-
tion before the alveolar bone grafting. In addition,
both authors suggested that, unlike the apex of the distal
tooth, the apex of the mesial tooth was not always cov-
ered by bone. In this situation, the clinician should not
use orthodontic force to prevent root resorption. At T1
and T2, there were no statistically significant differences
between the Bergland bone levels at sites 1 and 2. These
data correlated with good stability of the bone grafts and
indicated the periodontal health of both mesial and dis-
tal teeth adjacent to the cleft side.
Another interesting finding of this study was that, at
T2, 38 of the 49 patients (77.55%; 95% CI, 63.38-88.23)
had spontaneous canine eruption through the grafted
bone. The success rate in this sample is comparable
with the average percentage reported in the literature
(75%). Previously reported success rates of bone graft
are 97% (Turvey et al23), 95% (Troxell et al45), 95%
(Long et al17), 92% (Enemark et al24), 85% (Bergland
et al25), 80% (Boyne and Sands15), 73% (Nicholson
and Plint46), and 72% (Da Silva Filho et al37). Bone graft
integration was radiographically and histologically veri-
fied.47 However, El Deeb et al21,48 reported spontaneous
eruptions in only 27% and 41% of the canines. They
attributed their findings to the bone graft material and
the surgical technique used. Bergland et al25 clarified
that wide flaps of alveolar mucosa impede canine erup-
tion and increase further surgical exposure.
We believe that the following factors are involved in
spontaneous canine eruption in cleft patients: (1) arch
development with previous orthopedic expansion, (2)
September 2012 ! Vol 142 ! Issue 3
296
creation of space for canine eruption with orthodontic
therapy, and (3) periodontal health of the canine with re-
spect to the root during the graft surgery. In addition, the
grafted bone itself plays a basic role by triggering a cyto-
kine cascade through interactions between the bone and
the canine follicle. The molecular basis of this phenom-
enon is not well characterized yet. Occasionally, canines
require an orthodontic stimulus to erupt in the correct
position. In our study, 11 patients (22.44%; 95% CI,
11.77-36.62) had canine impactions and required a sur-
gical flap and orthodontic recovery. The exposure per-
centage of the canines varies in the literature, ranging
from 9%48 to 17%,21 and the need for orthodontic trac-
tion is 5% to 56%.21,37,41,48,49 Patients with alveolar
clefts have a 20-fold increased risk for canine impaction
(18.9%50-35%51) compared with the general population
(1%-2%).52
Further research is needed to determine the correla-
tion between canine impaction and bone height,
because canine impactions might affect the bone height
vs having a canine erupt into the graft. In this study, we
found only 1 patient with canine impaction and incom-
plete bone height at T2. Therefore, canine impaction
seemed not to affect the bone height after the bone
graft.
In this study, 65.31% (95% CI, 50.36-78.33) of the
patients had lateral incisor agenesis; this is lower than
reported by Akcam et al53 (70.8%-97.1%) but higher
than reported by Dewinter et al54 (50%). The high rate
of dental anomalies on the cleft side might be due to
a deficient blood supply or ectodermal and mesodermal
tissues during embryogenesis. We found that spontane-
ous canine eruption at T2 was not significantly associ-
ated with lateral incisor agenesis. This is in accordance
with the study of Gereltzul et al,55 who reported no ef-
fect of the lateral incisor on canine eruption. However,
Russell and McLeod43 studied 101 cleft sides in patients
with complete unilateral or bilateral cleft lips and cleft
palates and found that 61% of those with abnormally
positioned canines also had abnormal lateral incisors.
In addition, there were more canines with an abnormal
vertical position before alveolar bone grafting when
the lateral incisor was missing. We concluded that the
absence or anomalies of the lateral incisors might influ-
ence canine eruption and increase the risk for canine im-
paction. However, thus far, no data support this
relationship.
Spontaneous canine eruption at T2 was not signifi-
cantly associated with cleft severity at T0. This finding
was never previously investigated, and it might result
from complete healing of the cleft side after bone graft-
ing, allowing a physiologic canine eruption through the
remodeled bone.
September 2012 ! Vol 142 ! Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Toscano et al
We observed a difference between the type of cleft
and spontaneous canine eruption on the cleft side. In
patients with bilateral clefts, there was only 1 with a nor-
mal canine pattern of eruption at T2. But with only 4
patients (8.16%, 95% CI, 2.27-19.6) in the bilateral cleft
group, we cannot use statistics to draw inferences about
these 2 groups. However, alterations in eruption were
probably due to a more serious impairment of the max-
illary structure. The presence of deciduous teeth, lateral
incisor guidance, and interactions between cytokine and
bone are all well-characterized factors that influence ca-
nine eruption, which is usually absent or more compro-
mised in bilateral than in unilateral cleft patients.
In this study, only 3 patients (6.12%; CI, 1.28-16.87)
had lost teeth adjacent to the cleft side at T2. Two pa-
tients had peg-shaped lateral incisors, and 1 patient
had microdontic supernumerary teeth instead of a lateral
incisor; these were extracted during the graft surgery.
This finding concurs with the findings of Long et al,17
who reported the loss of 3 teeth, accounting for a failure
rate of 5%. In contrast, Helms et al26 reported failure
rates of 22% and 59% in their study. All teeth lost
were lateral incisors with anomalies in size, root and
crown shapes, and altered periodontal support. Tooth
loss adjacent to the cleft at T2 did not correlate with cleft
severity or type of cleft at T0. This finding has not been
investigated previously.
We also assessed any supernumerary and diminutive
teeth outside the cleft area. There were 12 (24.48%; 95%
CI, 13.34-38.87) patients with diminutive teeth outside
the cleft area. None had supernumerary teeth far from
the cleft side. Previously, Dewinter et al54 also reported
agenesis outside the cleft area in 27.2% of patients,
and Brattst€ om and McWilliam42 reported a 27.8% rate
of agenesis in unilateral cleft lip and cleft palate pa-
tients. In contrast, Akcam et al53 showed rates from
12.5% to 52.8% for noncleft side agenesis in the ante-
rior, premolar, and molar regions; this was explained
by the severity of the cleft phenotype.
This study confirms the benefit of secondary bone
grafts. By eliminating the gap, rehabilitating the alveolar
morphology, and facilitating the eruption of teeth, bone
grafting allows alveolar bone to develop and supports
the normal functions of the teeth.
Previous studies have confirmed the importance of
several variables involved in the long-term stability of
alveolar bone grafts. These include the initial severity
of the cleft, the surgical technique and the surgeon’s
technical skills, the handling of tissues during the graft
procedure, the type of graft material, the periodontal
status of teeth in the proximal segment at the bone
grafting, and the eruption stage of the teeth in the distal
segment.
Toscano et al
We analyzed the variables of age (at bone graft-
ing), sex, cleft severity and type of cleft, lateral agen-
esis, and grading system by keeping other variables
constant, such as the surgeon and the surgical
bone-graft technique, the radiologist and the radio-
graphic technique, the type of graft material, the
eruption stage of the teeth in the distal segment,
and the treatment protocol. According to our data,
there was no significant correlation between age or
sex and the long-term stability of the bone graft.
There was also no significant association between
cleft severity (minor, moderate, severe) at T0 and the
success of the alveolar graft at T2, or between the
type of cleft (unilateral or bilateral) and the stability
of the alveolar graft. Finally, we found no significant
correlation between lateral incisor agenesis on the
cleft side and the long-term success of bone grafts.
These findings implicate other factors that might
cause the variability in the long-term stability of
bone grafts.
Based on the evidence from this clinical trial, it is rea-
sonable to assume that factors involved in the success of
the bone graft are dental age at the time of bone grafting
and the surgical and orthodontic protocol. Previous
studies have emphasized the importance of exploiting
the eruptive force of the incomplete canine root on the
cleft side and performing appropriate surgical proce-
dures to aid in tissue healing and bone-graft stabil-
ity.17,25 However, no prior studies have addressed the
importance of orthodontic therapy on the long-term
stability of bone grafts. Only 1 study mentioned ortho-
pedic treatment as a probable variable in the success
of the primary bone graft; however, there was no ortho-
dontic protocol, and the orthodontic role in the study
population was unclear.26 Da Silva Filho et al37 under-
lined the role of the bone graft in canine eruption and
emphasized that pregraft orthodontic treatments yield
better access for the surgeon and that postgraft ortho-
dontic procedures can correct the positions of the per-
manent teeth in the grafted area. However, they did
not consider that canines that are protruding through
the bone graft have a functional role in the stability of
the bone graft. Feichtinger et al56 reported that the av-
erage loss of bone was 52% in the third year after surgery
and clarified the importance of canine and lateral incisor
eruption through the graft. They did not emphasize the
role of orthodontic therapy.
We agree with the study by Long et al17 and believe
that it is important to achieve orthopedic maxillary
protraction and expansion before graft surgery. If
expansion is carried out after bone grafting, fistulae
can appear, leading to an additional surgical procedure.
The palatal expansion increases the transverse maxillary
American Journal of Orthodontics and Dentofacial Orthopedics
297
dimension and the sagittal projection of the nasal spine
and improves the growth prognosis and the percentage
of spontaneous canine eruptions. Even though Russell
and McLeod43 asserted that this conclusion is not sup-
ported by the literature, many studies have confirmed
the benefits of rapid maxillary expansion in noncleft pa-
tients57-60 and cleft patients.61,62 In noncleft patients,
separation occurs in the midpalatal suture. However, in
cleft patients, there is a separation between the maxilla
and the premaxilla without osseous gain, as well as
asymmetric bone movement in unilateral cleft patients
because of their maxillofacial structure. Therefore,
many authors agree on the necessity and efficiency of
early transverse expansion in cleft patients.61,63
After surgery, it is necessary to prevent a relapse by
preserving the transverse maxillary dimension with
a transpalatal bar. It is also necessary to encourage
transverse alveolar development through orthodontic
multi-bracket appliances. The application of biologic
force facilitated tooth eruption on the grafted bone
and contributed to its long-term stability. Biology sup-
ports the resorption of bone in the absence of functional
stresses. In this case, the eruption of teeth (lateral incisor
and canine) and their proper placement through bone
grafting are the functional elements of the long-term
stability of bone grafts. In the case of diminutive teeth
and residual spaces after orthodontic therapy, the
grafted side must be restored with functioning pros-
thetic teeth (implants) as soon as possible to prevent fur-
ther bone loss. The long-term stability of dental implants
in the cleft side ranges from 82.2%64 to 98.6%.65
A limitation of this study was the absence of a control
group. However, not treating patients with cleft lips and
cleft palates is unethical because of a consensus on the
therapeutic benefits.
It is reasonable to assume that our protocol is an ad-
equate form of treatment for cleft lip and palate pa-
tients. It reduces the need for maxillofacial surgery at
the completion of growth, and it positively affects the
long-term stability of bone grafts with a greater survival
rate of the teeth adjacent to the cleft.
CONCLUSIONS
Based on our data, it seems appropriate to recom-
mend the early application of a surgical-orthodontic
protocol to treat cleft lip and palate patients, prevent
postoperative bone resorption, and guarantee correct
positioning of the teeth.
Our findings indicate the following.
1. The success rate of bone grafts at T2 was 91.84
(95% CI, 84.55-96.41), suggesting a high percent-
age of success with this therapy protocol.
September 2012 ! Vol 142 ! Issue 3
298
2. Cleft severity was not statistically correlated with
success at T2, demonstrating the protocol’s efficacy
and its ability to repair clefts of varying severity.
3. The concordance rate between the Bergland and the
Witherow-derived scales was 87.07% (95% CI,
82.69-90.69), indicating that this is a simple and re-
liable 2-dimensional method for assessing the suc-
cess of bone grafts as a useful clinical and
experimental tool.
Additional studies involving this surgical-
orthodontic protocol need to be conducted with a larger
sample size and a longer follow-up period.
REFERENCES
1. Skoog T. The use of periosteal flaps in the repair of clefts of the
primary palate. Cleft Palate Craniofac J 1965;2:332-9.
2. Rintala A, Ranta R. Primary treatment of cleft lip and palate at the
Finnish Red Cross Cleft Palate Center from 1966 to 1980. In:
Hotz M, Gnoinski W, Perko M, Nussbaumer H, Hof E,
Haubensak R, editors. Early treatment of cleft lip and palate. Tor-
onto, Ontario, Canada: Hans Hubert Publishers; 1986. p. 140-3.
3. Helloquist R, Sv€ardstr€om K, Pont"en B. A longitudinal study of de-
layed periosteoplasty to the cleft alveolus. Cleft Palate Craniofac J
1983;20:277-88.
4. Ranta R. Orthodontic treatment alternatives for unilateral cleft lip
and palate patients. In: Bardach J, Morris HL, editors. Multidisci-
plinary management of cleft lip and palate. Philadelphia: W. B.
Saunders; 1990. p. 637-41.
5. Kuijpers-Jagtman AM, Long RE Jr. The influence of surgery and
orthopaedic treatment on maxillofacial growth and maxillary
arch development in patients treated for orofacial clefts. Cleft Pal-
ate Craniofac J 2000;37:527.1-12.
6. Nordin KE, Johanson B. Freie knochentransplantation bei defcten
in alveolarkamm nach kieferorthop€adischer einstellung der maxilla
bei lippen-kiefer-gaumenspalten. In: Schuchardt K, Wassmund M,
editors. Fortschritte der Kiefer-und Gesichts-Chirurgie, Volume I.
Stuttgart, Germany: Georg Thieme Verlag; 1955. p. 168-71.
7. Schmid E. Die ann€aherung der kieferst€ umpfe bei lippen-kiefer-
gaumenspalten; ihre schadlichen folgen und vermeidung. In:
Schuchardt K, Wassmund M, editors. Fortschritte der Kiefer-und
Gesichts-Chirurgie, Volume I. Stuttgart, Germany: Georg Thieme
Verlag; 1955. p. 37-9.
8. Dado DV. Primary (early) alveolar bone grafting. Clin Plast Surg
1993;4:683-9.
9. Eppley BL. Alveolar cleft bone grafting (part I): primary bone graft-
ing. J Oral Maxillofac Surg 1996;54:74-82.
10. Robertson NRE. Early treatment—a critique. Trans Eur Orthod Soc
1973;547-52.
11. Smahel Z, M€ ullerova Z, Nejedly A, Horak I. Changes in craniofacial
development due to modifications of the treatment of unilateral
cleft lip and palate. Cleft Palate Craniofac J 1998;35:240-7.
12. Molsted K, Dahal E, Brattstr€ om V, McWilliam J, Semb G. A six-
center international study of treatment outcome in patients with
cleft lip and palate: evaluation of maxillary asymmetry. Cleft Palate
Craniofac J 1993;30:22-8.
13. Ross RB. Treatment variables affecting facial growth in complete
unilateral cleft lip and palate. Part 3: alveolus repair and bone
grafting. Cleft Palate Craniofac J 1987;24:33-44.
September 2012 ! Vol 142 ! Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Toscano et al
14. Berkovitz S. A comparison of treatment results in complete bilat-
eral cleft lip and palate using a conservative approach versus
Millard-Latham PSOT procedure. Semin Orthod 1996;2:169-84.
15. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar
and palatal defects. J Oral and Maxillofac Surg 1972;30:87-92.
16. Boyne PJ, Sands NR. Combined orthodontic-surgical management
of residual palato-alveolar cleft defect. Am J Orthod 1976;70:
20-37.
17. Long RE Jr, Spangler BE, Yow M. Cleft width and secondary al-
veolar bone graft success. Cleft Palate Craniofac J 1995;35:
420-7.
18. Brattstr€om V, McWilliam J, Larson O, Semb G. Craniofacial devel-
opment in children with unilateral clefts of the lip, alveolus, and
palate treated according to four different regimes. I. Maxillary de-
velopment. Scand J Plast Reconstr Surg Hand Surg 1991;25:
259-67.
19. Brattstr€om V, McWilliam J, Semb G, Larson O. Craniofacial devel-
opment in children with unilateral clefts of the lip, alveolus, and
palate treated according to four different regimes. II. Mandibular
and vertical development. Scand J Plast Recontr Surg Hand Surg
1992;26:55-63.
20. Bertz JE. Bone grafting of alveolar clefts. J Oral Surg 1981;39:
874-7.
21. El Deeb M, Messer LB, Lehnert MW, Hebda TW, Waite DE. Canine
eruption into grafted bone in maxillary alveolar cleft defects. Cleft
Palate J 1982;19:9-16.
22. Hall HD, Posnick JC. Early results of secondary bone grafts in 106
alveolar clefts. J Oral Maxillofac Surg 1983;41:289-94.
23. Turvey AT, Vig K, Moriarty J, Hoke J. Delayed bone grafting in the
cleft maxilla and palate: a retrospective multidisciplinary analysis.
Am J Orthod 1984;86:244-56.
24. Enemark H, Krantz-Simonsen E, Schramm JE. Secondary bone
grafting in unilateral cleft lip and palate patients: indications
and treatment procedures. Int J Oral Surg 1985;14:2-10.
25. Bergland O, Semb G, Abyholm F. Elimination of residual al-
veolar cleft by secondary bone grafting and subsequent or-
thodontic treatment. Cleft Palate Craniofac J 1986;23:
175-205.
26. Helms JA, Spiedel MT, Denis KL. Effect of timing on long-term
clinical success of alveolar bone grafts. Am J Orthod Dentofacial
Orthop 1987;92:232-40.
27. Enemark H, Sindet-Pedersen S, Bundgaard M. Long-term results
after secondary bone grafting of alveolar clefts. J Oral Maxillofac
Surg 1987;45:913-9.
28. Widmaier W. A surgery procedure for the closure of palate clefts.
In: Schuchardt K, editor. Operation of clefts of the hard and soft
palate, treatment of patients with cleft lip, alveolus and palate.
Stuttgart, Germany: Thieme; 1966. p. 87-9.
29. Perko M. A contribution to the problem of velo-pharyngeal incom-
petence. J Maxillofac Surg 1973;1:96-8.
30. Perko M. Two-stage closure of cleft palate (progress report). J
Maxillofac Surg 1979;7:76-80.
31. Celesnik F. Notre proc"ed"e de traitement chirurgical du bec-de-
li"evre bilateral total. Rev Stomatol 1962;63:386-8.
32. Tennison CW. The repair of unilateral cleft lip by the stencil
method. Plastic Recontr Surg 1952;9:115-20.
33. Sindet-Pedersen S, Enemark H. Recontruction of alveolar clefts
with mandibular or iliac crest bone grafts: a comparative study.
J Oral and Maxillofac Surg 1990;48:554-8.
34. Witherow H, Cox S, Jones E, Carr R, Waterhouse N. A new scale to
assess radiographic success of secondary alveolar bone grafts. Cleft
Palate Craniofac J 2002;39:255-60.
Toscano et al
35. Amanat N, Langdon JD. Secondary alveolar bone grafting in clefts
of the lip and palate. J Craniomaxillofac Surg 1991;19:7-14.
36. Kindelan JD, Nashed RR, Bromige MR. Radiographic assessment
of secondary autogenous bone grafting in cleft lip and palate pa-
tients. Cleft Palate Craniofac J 1997;34:195-8.
37. Da Silva Filho OG, Teles SG, Ozawa TO, Filho LC. Secondary bone
graft and eruption of the permanent canine in patients with alve-
olar clefts: literature review and case report. Angle Orthod 2000;
70:174-8.
38. Lilja J, Kalaaji A, Friede H, Elander A. Combined bone grafting and
delayed closure of the hard palate in patients with unilateral cleft
lip and palate: facilitation of lateral incisor eruption and evalua-
tion of indicators for timing of the procedure. Cleft Palate Cranio-
fac J 2000;37:98-105.
39. Jia Y, Mars M. Long-term evaluation of bilateral alveolar bone
grafting. Zhonghua Kou Quing Yi Xue Za Zhi 2000;35:368-70.
40. Aurouze C, Moller KT, Bevis RR, Rehm K, Rudney J. The presurgical
status of the alveolar cleft and success of secondary bone grafting.
Cleft Palate Craniofac J 2000;37:179-84.
41. Paulin G, Astrand P, Rosenquist JB, Bartholdson L. Intermediate
bone grafting of alveolar clefts. J Craniomaxillofac Surg 1988;
16:2-7.
42. Brattstr€om V, McWilliam J. The influence of bone grafting age on
dental abnormalities and alveolar bone height in patients with uni-
lateral cleft lip and palate. Eur J Orthod 1989;11:351-8.
43. Russell KA, McLeod CE. Canine eruption in patients with complete
cleft lip and palate. Cleft Palate Craniofac J 2008;45:73-80.
44. Teja Z, Persson R, Omnell ML. Periodontal status of teeth adjacent
to non-grafted unilateral alveolar clefts. Cleft Palate Craniofac J
1992;29:357-62.
45. Troxell JB, Fonseca RJ, Osbon DB. A retrospective study of alveolar
grafting. J Oral Maxillofac Surg 1982;40:721-5.
46. Nicholson PT, Plint DA. A long-term study of rapid maxillary
expansion and bone grafting in cleft lip and palate patients. Eur
J Orthod 1989;11:186-92.
47. Boyne PJ. Use of marrow-cancellous bone grafts in maxillary alve-
olar and palate clefts. J Dent Res 1974;53:821-4.
48. El Deeb M, Hinrichs JE, Waite DE, Bandt CL, Bevis R. Repair of
alveolar defects with autogenous bone grafting: periodontal
evaluation. Cleft Palate Craniofac J 1986;23:126-36.
49. Kwon HJ, Waite DE, Stickel FR, Chisholm T, McParland F. The
management of alveolar cleft defects. J Am Dent Assoc 1981;102:
848-53.
50. Matsui K, Echigo S, Kimizuka S, Takahashi M, Chiba M. Clinical
study on eruption of permanent canines after secondary alveolar
bone grafting. Cleft Palate Craniofac J 2005;42:309-13.
51. Enemark H, Jensen J, Bosh C. Mandibular bone graft material for
reconstruction of alveolar defects. Long-term results. Cleft Palate
Craniofac J 2001;38:155-63.
American Journal of Orthodontics and Dentofacial Orthopedics
299
52. Bass TB. Observations on the misplaced upper canine tooth. Dent
Pract Dent Rec 1967;18:25-33.
53. Akcam MO, Evirgen S, Uslu O, Memikoglu UT. Dental anomalies in
individuals with cleft lip and/or palate. Eur J Orthod 2010;32:
207-13.
54. Dewinter G, Quirynen M, Heidb€ uchel K, Verdonck A, Willems G,
Carels C. Dental abnormalities, bone graft quality and periodontal
conditions in patients with unilateral cleft lip and palate at differ-
ent phases of orthodontic treatment. Cleft Palate Craniofac J
2003;40:343-50.
55. Gereltzul E, Baba Y, Ohyama K. Attitude of the canine in secondary
bone-grafted and nongrafted patients with cleft lip and palate.
Cleft Palate Craniofac J 2005;42:679-86.
56. Feichtinger M, Mossb€ ock R, K€archer H. Assessment of bone
resorption after secondary alveolar bone grafting using three-
dimensional computed tomography: a three-year study. Cleft Palate
Craniofac J 2007;44:142-8.
57. Sigler LM, Baccetti T, McNamara JA Jr. Effect of rapid maxillary
expansion and transpalatal arch treatment associated with decid-
uous canine extraction on the eruption of palatally displaced ca-
nines: a 2-center prospective study. Am J Orthod Dentofacial
Orthop 2011;139:e235-44.
58. Armi P, Cozza P, Baccetti T. Effect of RME and headgear treatment
on the eruption of palatally displaced canines: a randomized clin-
ical study. Angle Orthod 2011;81:370-4.
59. Baccetti T, Sigler LM, McNamara JA Jr. An RCT on treatment of
palatally displaced canines with RME and/or a transpalatal arch.
Eur J Orthod 2011;33:601-7.
60. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive treat-
ment of palatal impaction of maxillary canines with rapid maxillary
expansion: a randomized clinical trial. Am J Orthod Dentofacial
Orthop 2009;136:657-61.
61. Capellozza Filho L, De Almeida AM, Ursi WJ. Rapid maxillary
expansion in cleft lip and palate patients. J Clin Orthod 1994;
28:34-9.
62. Wang D, Cheng L, Wang C, Quian Y, Pan X. Biomechanical analysis
of rapid maxillary expansion in the UCLP patients. Med Eng Phys
2009;31:409-17.
63. Tindlund RS, Rygh P, Boe OE. Intercanine widening and sagittal
effect of maxillary transverse expansion in patients with cleft lip
and palate during the deciduous and mixed dentitions. Cleft Palate
Craniofac J 1993;30:195-207.
64. Kramer FJ, Baethge C, Swennen G, Bremer B, Schwestka-Polly R,
Dempf R. Dental implants in patients with orofacial clefts:
a long-term follow-up study. Int J Oral Maxillofac Surg 2005;
34:715-21.
65. Matsui Y, Ohno K, Nishimura A, Shirota T, Kim S, Miyashita H.
Long-term study of dental implants placed into alveolar cleft sites.
Cleft Palate Craniofac J 2007;44:444-7.
September 2012 ! Vol 142 ! Issue 3