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Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 154-157

Autologous alveolar bone graft integration based on the Bergland scale in patients with primary lip and palate cleft: Experience in a third level hospital in Mexico City

Division of Plastic and Reconstructive Surgery, Cleft Lip and Palate Clinic, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico

Date of Web Publication11-Aug-2017

Correspondence Address:
Jorge Raúl Carrillo-Córdova
Hospital General “Dr. Manuel Gea González”, Av. Calzada de Tlalpan 4800, Tlalpan, Mexico City 14080
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_19_17

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Introduction: Alveolar bone graft surgery is of crucial importance in the cleft lip and palate patient. Adequate integration of the bone promotes dentition and esthetic of the face. The aim of this study is to evaluate the integration of the bone graft in patients with primary palate cleft. Patients and Methods: We made a retrospective analysis of medical records and plain X-ray films of 37 patients undergoing bone graft surgery in a tertiary care center. To assess the integration rate, we used the Bergland scale. Integration of alveolar bone graft evaluated with orthopantomography and relation between sex and the type of alveolar cleft surgery in the bone integration. Results: About 65% of the patients in our series were male (24). There was no statistical difference between the age, sex, and diagnosis. Mean age of the patients was 10.2 years. Successful integration (Bergland scale I and II) was achieved in 49% of the patients (Grade I: 30% and Grade II: 19%). Unfavorable integration (Bergland scale III and IV) was demonstrated in 51% of the patients, (Grade III: 43% and Grade IV: 8%). We found no difference between the integration rate and the type of alveolar graft surgery (primary, conventional secondary, and late secondary). Conclusions: Using the Bergland scale, we demonstrated 49% successful integration of the alveolar bone analyzed by two experts. Age has no impact on the integration rates in these groups of patients.

Keywords: Alveolar bone graft, cleft lip and palate, orthopantomography

How to cite this article:
Perez-Gonzalez A, Shinji-Pérez K, Theurel-Cuevas A, Jimenez-Murat Y, Carrillo-Córdova JR. Autologous alveolar bone graft integration based on the Bergland scale in patients with primary lip and palate cleft: Experience in a third level hospital in Mexico City. J Cleft Lip Palate Craniofac Anomal 2017;4:154-7

How to cite this URL:
Perez-Gonzalez A, Shinji-Pérez K, Theurel-Cuevas A, Jimenez-Murat Y, Carrillo-Córdova JR. Autologous alveolar bone graft integration based on the Bergland scale in patients with primary lip and palate cleft: Experience in a third level hospital in Mexico City. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2021 Dec 2];4:154-7. Available from: https://www.jclpca.org/text.asp?2017/4/2/154/212833

  Introduction Top

Cleft lip and palate is a well-recognized disorder in Mexico with the prevalence of 1.39 per 1000 newborn.[1] The management of these patients requires a specialized and multidisciplinary team. Most cases correspond to primary unilateral cleft lip and palate. Most bone grafts done in our institution are cancellous iliac bone grafts; this technique has the best integration rates reported worldwide. Morbidity of the donor site is minimum and outcome of the patients is good with ambulation in 3 days with few complications. At this point, autologous grafts are the one with more acceptance in cleft patients. They are divided in cortical and cancellous, depending on their origin.[2]

Another important aspect of the alveolar cleft treatment is the age at the time of surgery. Boyne established a useful classification based on the age of the patient. This classification goes from primary to secondary (early, intermediate, and late). The most frequently used in our service is conventional secondary which goes from the 6th to 12th year. The reasons why we propose to operate patient with alveolar cleft at this age are: to promote canine eruption, to generate less alteration to mid-face skeleton growth, and to obtain less reabsorption rates.[3],[4]

Bone graft integration can be evaluated with the Bergland scale; this validated instrument is divided into four groups depending on the amount of integrated bone and its relationship with the interalveolar septum as shown in [Figure 1]. Bergland scale is divided into:[5]
Figure 1: Bergland scale. Each grade depends on the grade of integration according to the height of the interalveolar septum

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  • Grade I: Ossifications equals the height of the interalveolar septum
  • Grade II: Ossification at least at 75% of the interalveolar septum
  • Grade III: Ossification is <75% of the interalveolar septum height
  • Grade IV: No evidence of bone integration.

Grade I and II corresponds to successful integration, whether Grade III and IV determines inadequate or none integration of the bone graft.

Orthopantomographies are a good method to assess Bergland scale, although it has some inconveniences such as image distortion and structure superpositioning.[6]

The aim of the present study was to evaluate the integration rate of autologous alveolar bone graft in patients with complete palatal cleft during June 2010–June 2015 based of the radiological Bergland scale.

  Patients and Methods Top

An observational, retrospective study was done to assess the integration of bone graft in patients with alveolar cleft using two-dimensional (2D) dental X-ray. During June 2010 to June 2015, 57 patients with unilateral primary cleft lip and palate were analyzed. Twenty files did not have accurate imaging for analysis and were eliminated from the study. A total of 37 patients underwent X-ray analysis and were included in statistical analysis. The radiologic evaluation was made by two experienced doctors from the Cleft clinic in our hospital 12 months after the bone graft surgery. Bergland scale was used to determine the integration of the bone graft comparing the preoperative X-ray with the postoperative one. Two experienced orthodontics previously evaluated bone graft integration reports with an interobserver concordance of 0.96 did an evaluation. To assess the quality of the evaluators, Rho coefficient was calculated during a test period obtaining a coefficient of 0.96.

Statistical analysis

Statistical analysis including mean, standard deviation, and variance were used to calculate the reliability of measurements. To assess any difference between the grade of integration and type of graft and sex, Chi-square test was done. Descriptive statistical analysis using IBM Corp. Released 2011, IBM SPSS Statistics for Windows, Version 20.0, Armonk, NY, USA: IBM Corp., was performed. P = 0.05 or less was considered statistically significant.

Patient consent and ethics

All surgical procedures and interventions were done according to Mexican Health law obtaining informed consent from all tutors. Parents or guardians provided written consent for the use of patient's information and images. Procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975, as revised in 2000.

  Results Top

Thirty-seven patients were included in the final analysis, 65% male (24 cases) with a mean age of 10.3 years. About 49% of the patients had successful integration according to Bergland scale (Grade I: 30% and Grade II: 19%). In 51% of the patients Bergland score showed a nonsuccessful integration (Grade III: 43% and Grade: IV 8%). These results are represented in [Figure 2]. Patients from each Bergland group, gender, and mean age are described in [Table 1]. We found no statistical difference between the integration rate and the type of graft (secondary conventional, secondary, or late secondary). We used Student's t-test to evaluate differences between sex and bone integration with a P = 0.120. Some cases of each group in this series are illustrated in [Figure 3].
Figure 2: Percentage of patients and their integration grade base don Bergland scale

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Table 1: Gender, mean age, and integration grade

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Figure 3: Different examples of orthopantomographies demonstrating alveolar bone integration

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  Discussion Top

Since the original description of Boyne and Sand in 1972, secondary autologous bone graft is the most common surgery in an alveolar cleft in patients with cleft lip and palate.[7] Benefits of this surgery have been reported by different authors showing the importance of this procedure in the canine descent, bone bridge in the alveolar (maxillary) cleft in patients undergoing orthognathic surgery, better esthetics and possibility of having osteointegrated implant, among others.[8],[9]

Bone graft evaluation after the surgery can be done with radiographic studies. 2D plain film is a useful study, with validated results in the literature. Volumetric tomography (three-dimensional) is now the gold standard because of the low radiation, accessible cost, excellent clinical-radiologically reliability and capacity to recognise bone gap and bone graft integration. Subjectivity is an important problem when evaluating orthopantomographies, so we decided to perform a paired evaluation of the studies. This evaluation was performed by expert orthodontists (more than 5 years of training), and a kappa coefficient of correlation of 0.9 was obtained before this study demonstrating an adequate inter-evaluator concordance.[10]

Most authors report an integration rate of 80% in alveolar bone graft surgery. The most common problem is that there are different ways to evaluate this new bone formation. Bergland scale is a validated instrument that allows this evaluation in an easy and straightforward manner.[4],[11] Bergland Grade I, II, and III are usually accepted as a good bone graft integration. In this study, we were stricter and only Grade I and II were accepted a successful graft surgery.

Our study presents a rate of integration below that accepted in the literature (51%). The reason is that we do not consider patients with Bergland III to be successful integration, while in the other centers they do.

Montaño et al., made a similar study in 106 patients with alveolar cleft, in their series only two patients were Bergland grade IV, all patients older than 11 years had a successful integration.[12] Compared to our study, we did not find that age influenced the integration of the bone graft. Age may imply better integration of bone because it is easier to manipulate tissue during surgery and patients follow postoperative indications better.

At the time of evaluating the integration in our patients depending on sex, we could not find gender differences. This supports the data described by Brusati and cols. They analyzed 77 cases of alveolar bone graft, demonstrating same integration rates between two genders

Our low integration rate depends on different factors that have to be studied in the future; some hypotheses are: we are a teaching hospital with different year residents doing the surgeries.

We tried to find an association between age and sex with the degree of integration. We found no association between these two variables. Sample size can impact in the results, and larger series have to be achieved to find this association.

Orthodontics care is important in the prognosis of alveolar bone graft surgery; Clarkson et al. published an improvement of the bone integration in alveolar graft surgery from 58% to 95% using Bergland scale.[14] Currently, the alveolar bone graft procedure in our service has been standardized in search of improving the integration rate in our patients. First, patients are evaluated in sets by the orthodontic and plastic surgery team to estimate the amount of graft needed and to assess the size of the gap. Subsequently, intra operatively, all patients undergoing this procedure are tested for leakage to demonstrate adequate nasal floor closure. In the event of leakage, repair is performed as shown in [Figure 4]. Another aspect of vital importance is the postoperative splinting; this splint is provided by the orthodontic service and used in the patient until evidence of consolidation of the bone graft is identified as well as adequate canine reduction.
Figure 4: Clinical example of alveolar bone graft surgery. Before and after of placement of bone graft

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Study limitations

Bone graft integration was evaluated with a 2D orthodontic plain film. Resenstein showed in a previous study that this kind of imaging sobrestimates bone bridge in 25% of the patients.[15] Unfortunately, in our service, we do not have tomography to carry out the analysis of the cases in a pre- and post-operative way and the patients do not count on many occasions with the economic resources to carry out the study outside the hospital.

Furthermore, the information was obtained from the files of the patients in a retrospective way making the data capture more difficult. Nowadays, the computerized tomography is the gold standard for the evaluation. Another limitation is the sample size, being small difficult to find statistic difference between groups. The most important limitation is lack of standardization. That is why pre- and post-operative orthodontics should play a fundamental role in alveolar bone graft surgery. The average gap in our patients was 8 mm, and in the case of demonstrating evidence of pocket leakage, the nasal floor was closed. The postoperative splint was maintained for 2 months until the final evaluation and follow-up by the cleft lip and palate clinic. All these considerations were aimed to improve our results.

  Conclusions Top

Based on the results of this study, bone graft integration in our series is low using the plain X-film to determine it. Several interventions including volumetric assessment, correct nasal floor surgery, orthodontic cast, and patient education are now being done to improve bone graft integration.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Trigos EM, Guzmán-y López Figueroa ME. Analysis of incidence, prevalence and primary care in patients with cleft lip and palate. Cirugía Plástica de México 2003;13:35-9.  Back to cited text no. 1
Van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: Nonsyndromic cleft palate. Plast Reconstr Surg 2008;121 1 Suppl: 1-14.  Back to cited text no. 2
Coots BK. Alveolar bone grafting: Past, present, and new horizons. Semin Plast Surg 2012;26:178-83.  Back to cited text no. 3
Campbell A, Costello BJ, Ruiz RL. Cleft lip and palate surgery: An update of clinical outcomes for primary repair. Oral Maxillofac Surg Clin North Am 2010;22:43-58.  Back to cited text no. 4
Kawakami S, Hiura K, Yokozeki M, Seike T, Nakanishi H, Moriyama K. Prognostic implications of nasal cavity and cleft morphology in secondary bone grafting. Cleft Palate Craniofac J 2002;39:575-81.  Back to cited text no. 5
Eppley BL. Alveolar cleft bone grafting (Part I): Primary bone grafting. J Oral Maxillofac Surg 1996;54:74-82.  Back to cited text no. 6
Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 1972;30:87-92.  Back to cited text no. 7
Wiedel AP, Svensson H, Schönmeyr B, Becker M. An analysis of complications in secondary bone grafting in patients with unilateral complete cleft lip and palate. J Plast Surg Hand Surg 2016;50:63-7.  Back to cited text no. 8
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.  Back to cited text no. 9
Hynes PJ, Earley MJ. Assessment of secondary alveolar bone grafting using a modification of the Bergland grading system. Br J Plast Surg 2003;56:630-6.  Back to cited text no. 10
Kuo-Ting P, Noordhoff S, Kane A. Repair of unilateral cleft lip. In: Neligan P, editor. Plastic Surgery: Craniofacial, Head and Neck. United Kingdom: Elsevier; 2013. p. 516-48.  Back to cited text no. 11
Montaño LA, Rincón RH, Landa CS. Nasoalveolar bone graft integration range in patients with cleft lip and palate sequels. Rev Odontol Mex 2012;16:18-30.  Back to cited text no. 12
Brusati R, Garattini G. The early secondary gingivoperiostoplasty. Oral Maxillofac Surg Clin North Am 2000;3:443-53.  Back to cited text no. 13
Clarkson J, Paterson P, Thorburn G, El-Ali K, Richard B, Hammond M, et al. Alveolar bone grafting: Achieving the organisational standards determined by CSAG, a baseline audit at the Birmingham Children's Hospital. Ann R Coll Surg Engl 2005;87:461-5.  Back to cited text no. 14
Tai CC, Sutherland IS, McFadden L. Prospective analysis of secondary alveolar bone grafting using computed tomography. J Oral Maxillofac Surg 2000;58:1241-9.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

This article has been cited by
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