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Autogenous bone graft of an alveolar cleft area has the following advantages: (1) assistance in the closure of buccoalveolar oronasal fistula; (2) provision of bony support for unerupted teeth and teeth adjacent to the cleft; (3) formation of a continuous alveolar ridge to facilitate orthodontic correction of malocclusion; (4) supporting the nostril floor and alar base to improve nasal aesthetics. It has been well accepted in most craniofacial centers as routine procedure in cleft lip and palate rehabilitation. A new surgical technique for alveolar bone grafting has been introduced to the Chang Gung Craniofacial Center since July 1991. It provided a good exposure of the alveolar cleft, primary closure of the fistula and adequate volume of bone graft. A review of 27 consecutive alveolar bone grafting procedures performed in unilateral cleft lip and palate patients from July 1991 to June 1992 was presented. Patients have been followed up for at least 6 months. The alveolar bone graft was evaluated clinically and radiologically at one week, six months and one year after the surgery. The preliminary results indicated that the new surgical technique produced less chance of recurrent fistula, good postoperative gingival height, and improvement of nasal aesthetics. Based on the results of this new study we strongly advocate the use of this new surgical technique.
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The esthetic expectations of our patients can be met by doing a thorough initial examination with emphasis on periodontal health, caries incidence, occlusion, possible orthodontic corrections, esthetic needs, and economic concerns. Through proper communication with the patient, a written treatment plan can be developed that uses the various techniques of bleaching, cosmetic recontouring, direct resin bonding, porcelain veneering, or crowning to meet the patient's restorative needs. The most conservative noninvasive techniques should be evaluated first. Often, bleaching and partial direct bonding are all that is needed. If the dentition is badly worn or discolored, then more extensive treatment is indicated. Patients frequently have concerns about longevity of restorations or require very high levels of esthetic correction, which can only be accomplished with more invasive techniques. When patients understand what can be accomplished and are involved in the treatment decision, then successful results are assured. Esthetic restorative dentistry is probably the most rewarding aspect of practice today, but it is also the most challenging. New materials appear and techniques change so rapidly that it is sometimes difficult to keep up. Practitioners should acquire a thorough knowledge of available methods and materials, learn the limitations of these materials and techniques, and master skills through continuing education (courses, journals, and newsletters) as well as chairside repetition as new procedures become available.
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Three counties in Sweden (A, G, and W) with free orthodontic care and different orthodontic resources and geographic structures were studied in 1987. Samples of totally 942 young adults (mean age 18.8 years, SD 0.44) were examined concerning malocclusions and all orthodontic treatment provided by general practitioners or by orthodontic specialists. The care in a rural area (county G) with abundant specialist resources was based on specialist treatments easy assessable to the patients and supplemented by treatments, mainly without appliances and provided by general practitioners. There was a generous attitude of consultation with specialists and of providing treatment. The sparsity of specialist resources had in an urban area (county A) resulted in a greater restriction on providing treatments. The treatments were performed in a higher age and were, to a greater extent, not completed by the age of 19, and a smaller percentage of individuals were treated than in the other two counties. The care in a large rural area (county W) with long distances to the only specialist clinic was based on treatments provided by general practitioners. In spite of the few specialist resources there was a generous attitude of providing treatments. Interceptive methods were used to a great extent, and later completed with appliance therapy. According to a treatment priority index 44% of the untreated individuals in the three counties had malocclusions and an objective treatment need, and there were no significant differences between the counties. Regardless of differences in specialist resources and structure of the free public orthodontic care, a substantial and equal proportion of the untreated individuals in the counties had malocclusions with treatment need, but they had no treatment desire.