Reply: Secondary Alveolar Bone Grafting or Primary Periosteoplasty?

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Thank you for the opportunity to respond to Dr. Giacomina et al. The authors describe their technique for primary periosteoplasty. It is reasonable to assume that this modification offers superior periosteal blood supply; however, we do not really know whether the osteogenic potential is also enhanced. What we do know is that the various techniques of primary gingivoperiosteoplasty all have the capacity to induce bone. It seems that an important determinant for the outcome is cleft width, because protocols including presurgical alveolar molding to narrow the cleft have produced the more favorable results.
Groups advocating primary periosteal flaps have emphasized the benefit of obviating the secondary alveolar bone grafting procedure, and this can be achieved in approximately two-thirds to three-fourths of the patients. The point is to reduce the total burden of care for patients that frequently require extensive treatment during infancy, childhood, and early adulthood. It has not been made clear whether the primary gingivoperiosteoplasty negatively affects the outcome of secondary alveolar bone grafting in those patients where insufficient bone was formed—in the Uppsala series, it did. Long-term studies looking at the stability of the grafted bone and other aspects, such as occlusion, dental status, and frequency of anterior fistulae, are lacking. The type of orthodontic treatment, primary or later on in permanent dentition, is rarely presented. There is evidence that the combination of presurgical alveolar molding and primary gingivoperiosteoplasty increases the need for later Le Fort I advancement, which indicates negative effects on maxillary growth.1
Postponing alveolar reconstruction to the stage of mixed dentition was advanced as a way of reducing negative effects on growth. This procedure has consistently produced results, with 80 to 90 percent of patients scoring a Bergland index of 1. It should be integrated into a long-term surgical and orthodontic treatment plan. Surgery is timed with eruption of the permanent canine teeth and frequently preceded by orthodontic expansion to produce a more harmonious alveolar ridge form. Any remaining oronasal communication through the anterior aspect of the cleft is closed. In its entirety, this approach restores the bony platform that supports the nasolabial soft-tissue complex and facilitates further orthodontic and orthognathic work. As for long-term outcomes, we have previously reported on 10-year results.2 The once-grafted bone undergoes gradual degradation in approximately half of the patients. We identified preventable oral and dental factors affecting bone height and concluded that long-term orthodontic interceptive treatment is important for a stable long-term outcome. The success of alveolar cleft reconstruction depends on more than the surgery itself.
The treatment of patients with clefts is a complex, long-term, and interdisciplinary process frequently entailing multiple operations. The total burden of care is considerable. However, the greatest burden is put on patients with suboptimal results and scarred tissues from failed surgical procedures. Our philosophy is therefore to only perform operations and surgical maneuvers that we know will achieve the desired goal in the vast majority of patients. We look forward to further long-term evaluations of primary gingivoperiosteoplasty addressing the multiple outcome parameters relevant to alveolar cleft reconstruction.
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