Gingivoperiosteoplasty Matches Bone Grafting Success in Unilateral Clefts

Refining Alveolar Reconstruction in the Mixed Dentition Phase

Managing alveolar clefts, which affect approximately 75 percent of patients with cleft lip and palate, requires a multidisciplinary approach to stabilize the maxillary arch and provide bony support for erupting teeth [1, 2]. While secondary alveolar bone grafting using autologous iliac crest bone is a well-established standard, it carries risks of donor site morbidity and potential failure in patients with poor oral hygiene or advanced age [3, 1]. Less invasive alternatives like gingivoperiosteoplasty (a procedure that utilizes the osteogenic potential of the periosteum, the vascular connective tissue covering the bone, to bridge the defect) and nasoalveolar molding (a presurgical orthopedic technique used to approximate cleft segments) have been utilized to reduce the need for bone harvesting [4, 5]. However, historical data on the efficacy of these techniques have been inconsistent, with some evidence suggesting they may lead to maxillary growth inhibition or inferior bone quality compared to traditional grafting [6]. A new retrospective analysis now provides long-term comparative data on these two surgical strategies to clarify their roles in modern clinical practice.

Long-Term Comparative Analysis of Surgical Cohorts

The researchers conducted a retrospective study to evaluate the long-term outcomes of two primary surgical interventions for alveolar clefts: secondary gingivoperiosteoplasty (a procedure that relies on the osteogenic potential of the periosteum to bridge the bony defect) and secondary alveolar bone grafting (the surgical transplantation of bone tissue into the cleft). This analysis included a total of 100 patients who underwent treatment between 2014 and 2020. To ensure the durability of the surgical results and assess bone stability during mixed dentition (the developmental stage when both primary and permanent teeth are present), the study required a minimum follow-up duration of five years for all participants. Across this patient cohort, the researchers evaluated a total of 126 individual cleft sites, providing a dataset for comparing the efficacy of these techniques in both unilateral and bilateral alveolar cleft groups. This longitudinal perspective is essential for clinicians, as it tracks the stability of the reconstructed alveolus through the period of peak dental eruption and maxillary growth.

The study population was divided into two distinct surgical cohorts based on the procedure received. The secondary gingivoperiosteoplasty group comprised 57 patients, which included 38 patients with unilateral clefts and 19 patients with bilateral clefts. In comparison, the alveolar bone grafting group included 43 patients, consisting of 36 patients with unilateral clefts and 7 patients with bilateral clefts. By tracking these specific subgroups over the five-year period, the researchers aimed to determine how the choice of procedure influenced structural outcomes across different defect types. This granular breakdown of the 126 sites allowed for a direct comparison of how each surgical method performed in the context of varying cleft complexity, specifically focusing on the differences between one-sided and two-sided alveolar defects, which often present distinct challenges in tissue tension and vascular supply.

Standardized Radiographic and Clinical Assessment

To ensure clinical accuracy, the researchers evaluated all surgical outcomes during the mixed dentition phase, which is the specific developmental period when a child's mouth contains both primary and permanent teeth. This timing is critical for clinicians because the primary goal of alveolar reconstruction is to provide a stable bony matrix for the eruption of permanent teeth, particularly the maxillary canines. By assessing the 100 patients and 126 total cleft sites during this window, the study captured the functional success of the bone bridge at the exact moment it was most needed for dental development. The evaluation relied on two primary standardized clinical tools: the Bergland and Witherow scales. These metrics allow clinicians to grade the height and quality of the alveolar bone bridge, providing an objective measure of how much of the original bony defect has been successfully filled and maintained, with higher scores indicating sufficient bone for tooth eruption and periodontal health.

The radiographic protocol utilized a combination of traditional occlusal radiographs and cone-beam computed tomography (CBCT) scans. While occlusal films provide a two-dimensional view of the cleft area, the use of cone-beam computed tomography allowed for a more precise three-dimensional analysis of the bone volume and the integration of the graft or regenerated tissue within the maxillary arch. This rigorous imaging approach revealed that the success of the procedures varied significantly based on the type of cleft. In the unilateral groups, there was no statistically significant difference in success rates between gingivoperiosteoplasty and bone grafting (p = 0.755), suggesting both techniques are equally viable for single-sided defects. However, a statistically significant difference was identified in bilateral cases (p = 0.006), where the outcomes between the two surgical methods diverged, highlighting the importance of patient selection in complex, two-sided alveolar defects where the mechanical and biological demands on the surgical site are substantially higher.

Divergent Outcomes in Unilateral and Bilateral Defects

The statistical analysis of the five-year follow-up data indicates that the choice between surgical techniques may be less critical in patients with single-sided defects than in those with more complex presentations. In the unilateral cleft groups, no statistically significant difference in success rates was observed between gingivoperiosteoplasty and alveolar bone grafting (p = 0.755). This finding suggests that for the 38 patients in the gingivoperiosteoplasty group and the 36 patients in the bone grafting group with unilateral clefts, both procedures achieved comparable levels of alveolar reconstruction. For the clinician, this indicates that secondary gingivoperiosteoplasty, which involves the surgical manipulation of the periosteum (the dense layer of vascular connective tissue enveloping the bones) to encourage bone growth without a donor graft, can be as effective as traditional bone grafting in these specific cases, potentially sparing the patient a second surgical site.

The outcomes shifted significantly when the researchers evaluated more complex anatomical presentations involving both sides of the maxillary arch. In bilateral cleft cases, a statistically significant difference in outcomes was identified between the gingivoperiosteoplasty and alveolar bone grafting groups (p = 0.006). This divergence suggests that the physiological demands of repairing two alveolar defects simultaneously may limit the efficacy of certain techniques or require more stringent patient selection. While the study included 19 bilateral cases in the gingivoperiosteoplasty cohort and 7 in the bone grafting cohort, the clear statistical separation underscores that these two patient populations require distinct clinical considerations when planning secondary reconstruction during the mixed dentition phase.

Despite the differences noted in bilateral presentations, the data support the use of less invasive techniques in the appropriate clinical context. The researchers concluded that secondary gingivoperiosteoplasty provides reliable long-term outcomes in selected patients with alveolar clefts, particularly in unilateral cases. Because this procedure avoids the morbidity associated with harvesting autologous bone from the iliac crest, it represents a viable alternative for achieving a stable maxillary arch in the unilateral population. However, the authors emphasize that both techniques remain effective when appropriately indicated, and the significant difference in bilateral outcomes (p = 0.006) highlights that surgical success remains highly dependent on the specific morphology of the cleft and the individual patient's developmental needs.

Clinical Selection and Technical Limitations

The longitudinal data from this five-year retrospective study indicate that both secondary gingivoperiosteoplasty and secondary alveolar bone grafting are effective when appropriately indicated for the repair of alveolar clefts. For the practicing surgeon, the choice between these two methods involves balancing the invasiveness of the procedure against the anatomical requirements of the defect. While the study demonstrated that gingivoperiosteoplasty can achieve stable results without the need for harvesting autologous bone from the iliac crest (the crest of the pelvic bone), its success is contingent upon the specific clinical context of the patient. The researchers emphasized that the utility of either technique is maximized when the surgical approach is matched to the complexity and width of the cleft site, as wider defects may lack the necessary periosteal surface area to support spontaneous bone regeneration.

Despite the comparable outcomes observed in the unilateral cohorts (p = 0.755), the researchers noted that direct comparisons between gingivoperiosteoplasty and alveolar bone grafting should be interpreted cautiously due to differences in case selection. Because this was a retrospective analysis, the criteria for assigning a patient to a specific surgical group were not randomized; clinicians likely selected the surgical technique based on the initial severity of the cleft or the availability of local tissue. This inherent selection bias suggests that the high success rates for gingivoperiosteoplasty in unilateral cases may reflect its efficacy in patients with more favorable anatomy, whereas bone grafting remains a necessary standard for more challenging or wider defects where the biological scaffold of a graft is required to ensure stability.

Ultimately, the significant difference in outcomes for bilateral cases (p = 0.006) serves as a clinical reminder that more complex anatomical presentations may exceed the regenerative capacity of periosteal bridging alone. For clinicians managing patients in the mixed dentition phase (the period between ages 6 and 12 when both primary and permanent teeth are present), these findings support a nuanced approach to reconstruction. While secondary gingivoperiosteoplasty is a reliable and less invasive option for selected unilateral cases, the structural support provided by an autologous bone graft remains a critical component of the surgical armamentarium for complex bilateral defects, ensuring the long-term integrity of the dental arch.

References

1. Kim J, Jeong W. Secondary bone grafting for alveolar clefts: surgical timing, graft materials, and evaluation methods. Archives of Craniofacial Surgery. 2022. doi:10.7181/acfs.2022.00115

2. Rozzelle A, Eaton KJ. Cleft Lip and Palate and Isolated Cleft Palate. Pediatrics in Review. 2024. doi:10.1542/pir.2022-005557

3. Wu J, Zhuang J, Ma Y, Yin L, Wang Y. Risk factors associated with the failure of secondary alveolar bone grafting with autologous iliac crest bone in patients with alveolar cleft defects: a systematic review. Frontiers in Oral Health. 2025. doi:10.3389/froh.2025.1640933

4. Jahanbin A, Alizadeh F, Bardideh E, Sharifi S, Nazari MS. Does Presurgical Nasoalveolar Molding Reduce the Need for Future Bone Grafting in Cleft Lip and Palate Patients? A Systematic Review and Meta-Analysis. 2022. doi:10.1097/SCS.0000000000008616

5. Jahanbin A, Alizadeh FL, Bardideh E, Sharifi S, Nazari MS. Does Presurgical Nasoalveolar Molding Reduce the Need for Future Bone Grafting in Cleft Lip and Palate Patients? A Systematic Review and Meta-Analysis. Journal of Craniofacial Surgery. 2022. doi:10.1097/scs.0000000000008616

6. El-Ashmawi NA, Elkordy SA, Fayed MMS, El-Beialy A, Attia KH. Effectiveness of Gingivoperiosteoplasty on Alveolar Bone Reconstruction and Facial Growth in Patients With Cleft Lip and Palate: A Systematic Review and Meta-Analysis. The Cleft Palate-Craniofacial Journal. 2018. doi:10.1177/1055665618788421