Early secondary gingivo-alveolo-plasty in the treatment of unilateral cleft lip and palate patients : 20 years experience

Since 1988, the Milano surgical protocol has included lip, nose and soft palate repair at 6-9 months of age and closure of the hard palate at 18-36 months together with an Early Secondary Gingivo-Alveolo-Plasty (ESGAP). Prior to 1988 the alveolar cleft was repaired in a third step by bone grafting at 9-11 years of age. The goal of this study was to evaluate the long-term maxillary growth in unilateral cleft lip and palate (UCLP) patients who have undergone ESGAP. Alveolar ossification after ESGAP was also studied in the permanent dentition. Growth assessment was carried out comparing lateral X-ray cephalograms of a UCLP ESGAP sample (15 consecutive patients with a mean age of 18.2 +/-1.2 years) and of the UCLP bone graft sample (10 consecutive patients with a mean age of 18.7 +/-1.1 years) and a sample from the Oslo cleft lip and palate (CLP) centre sample (15 patients with a mean age of 18.1 +/-0.8 years). Alveolar ossification in the sample which had undergone ESGAP was evaluated through a sample of panoramic X-rays of UCLP in the permanent dentition. Alveolar bridging was assessed using a modified Bergland's scoring system. From the results it seems that ESGAP allows for an excellent alveolar ossification, but patients show an inhibition of maxillary growth compared with the secondary bone graft group and with the Oslo group. Although ESGAP allows for early repair of the alveolus together with palate repair, thus eliminating in all patients the need for secondary bone grafting, it seems to have an inhibiting influence on maxillary growth which increases the need for Le Fort I osteotomies. It is however fair to recall, that, even with an adjunctive Le Fort I osteotomy, ESGAP enables the total number of operations to be reduced to three, instead of most European protocols (4-5 procedures)