Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 391e398

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Journal of Cranio-Maxillo-Facial Surgery

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A novel success scale for evaluating alveolar cleft repair using

cone-beam computed tomography*
Georgios Kamperos a, *, Nadia Theologie-Lygidakis a, Kostas Tsiklakis b, Ioannis Iatrou a
a
University Department of Oral and Maxillofacial Surgery, ''P. & A. Kyriakou'' Children's Hospital (Head: Professor C. Perisanidis), School of Dentistry,
National and Kapodistrian University of Athens, Greece
b
Department of Oral Diagnosis and Radiology (Head: Professor K. Tsiklakis), School of Dentistry, National and Kapodistrian University of Athens, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Radiographic scales, based on plain radiographs, for the evaluation of alveolar cleft repair, have
Paper received 18 July 2019 certain weaknesses and are thought to overestimate to some degree the success of the surgical inter-
Accepted 10 February 2020 vention. The aim of this study was the presentation of a novel success scale for evaluating alveolar cleft
Available online 17 February 2020
repair using cone-beam computed tomography (CBCT).
Materials and methods: Patients treated with secondary osteoplasty for unilateral or bilateral alveolar
Keywords:
cleft were evaluated using the Bergland and Enemark scales, as well as the novel success scale, which
Alveolar cleft
measures the bone height, the bone width and the level of the nasal floor.
Secondary osteoplasty
Cone-beam computed tomography
Results: A total of 44 patients with a total of 53 alveolar cleft sites were included. According to the new
Outcome scale, 60% of the cases were defined as successful, with moderate (kappa ¼ 0.511) or substantial
(kappa ¼ 0.718) agreement, between the new scale and the Bergland or Enemark scale, respectively.
Statistically significant correlation was reported between the new success scale and the closure of space
of the lateral incisor, the patient's age at surgery, the graft revision and the presence of residual fistula.
Conclusions: The novel success scale for evaluating alveolar cleft repair using CBCT takes into consid-
eration all dimensions of the bony bridge. Future application is necessary for validation of its potential
value.
© 2020 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction
The alveolar cleft is characterized by a pyramid-shaped deficit,
extending over the alveolar process, towards the hard palate and
the nasal cavity, frequently leading to oronasal communication and
presence of fistula (Craven et al., 2007; Feichtinger et al., 2007). By
alveolar cleft repair, the continuity of the maxilla is restored
through a bony bridge, the oral and nasal cavities are separated and
the dental arch's development is supported (Bergland et al., 1986;
Lilja et al., 2000; Horswell and Henderson, 2003; Theologie-
Lygidakis et al., 2014). The timing for osteoplasty is still open to
debate. Secondary osteoplasty, during the mixed dentition, before
the eruption of the permanent canine in the area, is preferred in the
*
This work was supported by a scholarship [G ZN 017-1 / 2017e2018] from the
«Alexander S. Onassis Public Benefit Foundation».
* Corresponding author. 2-4, Alkmaionidon St, Kaisariani, 161 21, Greece.
E-mail address: gkamperos@yahoo.gr (G. Kamperos).
majority of cases, usually with autologous bone grafting (Boyne and
Sands, 1972; Bergland et al., 1986; Horswell and Henderson, 2003).
The radiographic dimensions of the bony bridge are considered
a primary success parameter for alveolar cleft repair. Special scales
are used for the outcome's evaluation, classifying the cases into
categories and proposing a threshold for characterizing each case as
acceptable or not acceptable. The most widely known is the Berg-
land scale (Bergland et al., 1986). The Enemark, Long, Kindelan,
Chelsea and SWAG scales have been also proposed in the literature
(Enemark et al., 1987; Long et al., 1995; Kindelan et al., 1997;
Witherow et al., 2002; Russell et al., 2016). All of them measure
the height of the bony bridge or the degree of bone fill in the cleft
area, with the use of periapical or occlusal x-rays. Until now, these
success scales, which are based only on plain radiographs, have
been considered the main way to evaluate the result of alveolar
cleft repair (Han et al., 2017; Kumar et al., 2017; Russell et al., 2017).
On the other hand, there are certain weaknesses in these scales.
First, plain radiographs cannot evaluate the thickness of the bony
bridge, which is a major factor for orthodontic movements and

https://doi.org/10.1016/j.jcms.2020.02.003
1010-5182/© 2020 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
392 G. Kamperos et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 391e398
dental implant placement (Lee et al., 1995; Iino et al., 2005;
Suomalainen et al., 2014). Second, conventional x-rays are charac-
terized by various imaging problems, such as distortion and
structure overlap (Waitzman et al., 1992; Hamada et al., 2005). As a
result, the success of the surgical intervention may be over-
estimated to some degree (Lee et al., 1995; Iino et al., 2005; Liu
et al., 2016).
The application of computed tomography (CT) for the post-
surgical follow-up of alveolar cleft patients attempts to address
these weaknesses. This technology enables measuring the exact
dimensions of the bony bridge, without distortion or structure
overlap (Waitzman et al., 1992; Iino et al., 2005; Suomalainen et al.,
2014; Meazzini et al., 2016). Most recent studies propose the use of
cone-beam computed tomography (CBCT), which offers high image
quality, with significantly reduced radiation dose compared to
conventional CT (Oberoi et al., 2009; Wangsrimongkol et al., 2013;
Suomalainen et al., 2014; Liu et al., 2015; Wang et al., 2016). Even
though several measuring systems based on CT have been reported,
none of them is particularly popular among the scientific com-
munity (Tai et al., 2000; Iino et al., 2005; Kim et al., 2008;
Marukawa et al., 2011; Wangsrimongkol et al., 2013; Calvo et al.,
2014; Suomalainen et al., 2014; Liu et al., 2015, 2016; Meazzini
et al., 2016; Shirota et al., 2016; Wang et al., 2016; Garib et al.,
2017; Han et al., 2017). Moreover, there is no single success scale
that takes into consideration all dimensions of the bony bridge. The
aim of this study was to present a novel success scale for evaluating
alveolar cleft repair using CBCT.
2. Materials and methods
2.1. Study patients
All young patients treated for alveolar clefts, during a 22-year
period (1995e2016) at the University Department of Oral and
Maxillofacial Surgery of “P. & A. Kyriakou” Children's Hospital in
Athens were recalled for the study. The research protocol was
approved by the Research Ethics Committee of the School of
Dentistry, National and Kapodistrian University of Athens (No. 332/
15th May 2017). Informed consent was obtained from all patients in
the study. The inclusion and exclusion criteria were the following:
Inclusion criteria:
 Complete alveolar cleft (absence of bony bridge), unilateral or
bilateral, with or without oronasal fistula
 Secondary osteoplasty (Boyne and Sands, 1972)
 Follow-up of at least 1 year after bone grafting
Exclusion criteria:
 Treatment with different surgical techniques
 Follow-up of less than 1 year after bone grafting
 No compliance to recall
2.2. Treatment history
Patients’ charts were reviewed for the following demographic,
presurgical and surgical information: age at surgery, gender,
follow-up, unilateral or bilateral alveolar cleft, cleft of the soft
palate, volume of bone deficit, presurgical and postsurgical ortho-
dontics, status of lateral incisor and canine adjacent to the cleft at
surgery, origin and form of bone graft, graft revision. Postsurgical
orthodontics was applied in all patients.
The volume of the bone deficit was calculated in the cases in
which presurgical CT was available. Measurements were made with
the free software InVesalius 3.1.1 (Center for Information Technol-
ogy Renato Archer, Campinas, Brazil). In coronal slices, the nasal
floor was defined as the upper edge of the cleft, and the alveolar
process of the neighboring teeth was defined as the lower edge. The
bone deficit was traced in every axial slice (Feichtinger et al., 2006,
2007, 2008). The volume of the bone deficit was then measured in
cubic centimeters (cm3).
2.3. Outcome evaluation
Each patient was examined clinically and radiographically at the
recall appointment, which is also the endpoint of the follow-up. In
bilateral cases, each cleft site was evaluated separately. The
following clinical postsurgical parameters were recorded: residual
fistula, spontaneous or orthodontically-assisted eruption of the
previously unerupted canine, preservation or closure of the space of
a missing or extracted lateral incisor.
2.3.1. Conventional radiographic examination
A periapical x-ray was taken for each cleft site with ORALIX AC™
(Gendex, Milano, Italy) using a sensor holder for paralleling tech-
nique (65 kVp, 7.5 mA, 0.16s). The imaging plate was scanned with
DIGORA™ Optime (Soredex, Tuusula, Finland).
The height of the bony bridge was evaluated with the Bergland
and Enemark scales, in the cases in which orthodontic movements
in the area were completed (Bergland et al., 1986; Enemark et al.,
1987). Bergland scale scores were determined as follows: type I,
interdental septum of approximate normal height; type II, inter-
dental septum at least three-fourths of normal height; type III,
interdental septum less than three-fourths of normal height; and
type IV, no continuous bony bridge across the cleft. Types I and II
were defined as success and types III and IV as failure. Enemark
scale scores were determined as follows: score 1, bone level at
75e100% of normal height; score 2, bone level at 50e75% of normal
height; score 3, bone level at 25e50% of normal height; and score 4,
bone level at 0e25% of normal height. Scores 1 and 2 were defined
as success and scores 3 and 4 as failure.
2.3.2. Cone-beam computed tomography examination
A CBCT scan was taken with NewTom VGi™ (QR s.r.l., Verona,
Italy) at 110 kV, choosing a field of view (FOV) of 12  8 cm and
boosted dose. Axial slices were reconstructed parallel to the
occlusal plane. Measurements were made with the manufacturer's
software NNT Viewer v. 7.2 (QR s.r.l., Verona, Italy).
The dimensions of the bony bridge were evaluated with a novel
success scale. The bone height and width, as well as the level of the
nasal floor, were semi-quantitatively measured in relation to the
adjacent teeth. In cases in which the canine remained unerupted,
measurements were made in relation to next adjacent erupted
tooth. As a result, the scale did not require the completion of the
orthodontic movements in the area.
 Bone height (H): multiple slices, which were reconstructed cor-
onal to the adjacent roots, were analyzed. The adjacent roots
were divided into four equal quarters. Each case was assigned a
score of H4 (best) to H1 (worst), according to the deepest
notching of the alveolar bone, as presented in Fig. 1 and Table 1.
If no continuous bony bridge was detected across the cleft, a
score of H0 was assigned.
 Bone width (W): an axial slice, which equally divided the bony
bridge between the adjacent roots, was analyzed. Each case was
assigned a score of W2 (best), if the bony bridge was more than
half the width of the adjacent roots, or W1 (worst), if the bony
bridge was less than half, labiopalatally, as presented in Fig. 1
 G. Kamperos et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 391e398
and Table 1. If no continuous bony bridge was detected across
the cleft, a score of W0 was assigned.
 Nasal floor (N): multiple slices, which were reconstructed cor-
onal to the adjacent roots, were analyzed. The adjacent roots
were divided into four equal quarters. Each case was assigned a
score of N4 (best) to N1 (worst), according to the greatest extent
of nasal floor, as presented in Fig. 1 and Table 1. If no continuous
bony bridge was detected across the cleft, a score of N0 was
assigned.
Consequently, each case was assigned three scores (H, W, N),
which were summed to form a total score: 10 for total success, 9 for
acceptable result, 8 for compromised result, 7 for unfavorable
result, 6 for extremely unfavorable result and 0 for total failure (no
bony bridge). Total scores 9e10 were defined as success and total
scores 0e8 as failure.
2.4. Statistical analysis
The various parameters of the patients were summarized as
mean value, standard deviation (SD) and range of values for
continuous variables and as absolute (n) and relative (%) frequency
for categorical variables. Statistical analyses were performed using
the SPSS software application (version 23: SPSS, Chicago, IL, USA)
with p < 0.05 as the threshold of significance.
On defining success versus failure of alveolar cleft repair, the
agreement between the new scale and the Bergland and Enemark
scales was measured by the kappa statistic. Values of more than
0.80 indicate almost perfect agreement, values 0.61e0.80 sub-
stantial agreement, values 0.41e0.60 moderate agreement, values
0.21e0.40 fair agreement and values less than 0.20 slight agree-
ment (Landis and Koch, 1977). On defining the height of the bony
bridge, the agreement between the new scale and the Enemark
scale was also measured by kappa statistic.
For the success of the alveolar cleft repair, a multiple logistic
regression model was not possible because of the small sample. As
a result, only univariate analysis was done, evaluating possible
associations between the various parameters and the new success
scale, using Kruskal-Wallis test, Mann-Whitney U test, Fisher exact
test and chi-square test. It is acknowledged that any possible as-
sociations should be interpreted with caution, due to the small
sample and the multiple statistical tests.
3. Results
During the studied period, 44 patients met the above-
mentioned criteria and were included in the study. They con-
sisted of 32 male and 12 female individuals, with a mean age of
11.9 years at surgery. The total alveolar cleft sites were 53. Patients’
demographics, presurgical, surgical and postsurgical parameters
Fig. 1. Schematic illustration of the new success scale for alveolar cleft repair: bone height e H, coronal slice (a), bone width e W, axial slice (b), nasal floor e N, coronal slice (c).
393
are presented in Table 2. The outcome evaluation, using the Berg-
land and Enemark scales is presented in Table 3. Seven patients, in
whom orthodontic movements in the area were not completed,
were not evaluated using the traditional two-dimensional scales.
According to the Bergland scale, type III (41%) was most commonly
reported, followed by type I (30%). The 57% of the cases was defined
as successful (types I and II). According to the Enemark scale, score
1 (57%) was most commonly reported, followed by score 3 (17%).
The 72% of the cases was defined as successful (scores 1 and 2). The
outcome evaluation, using the new scale, is presented in Table 4.
According to this new scale, bone height H4 (43%), bone width W2
(66%) and nasal floor N4 (85%) were most commonly reported. A
total score of 10 (36%) was most commonly reported, followed by a
total score of 9 (25%). Representative cases evaluated using the new
scale are presented in Fig. 2, for each possible total score. The 60% of
the cases was defined as successful (total scores 9 and 10). A suc-
cessful and a failed clinical case, evaluated using the new scale, are
presented in Fig. 3.
On defining success versus failure, there was moderate agree-
ment (kappa ¼ 0.511, p ¼ 0.001) between the new scale and the
Bergland scale, and substantial agreement (kappa ¼ 0.718,
p < 0.001) between the new scale and the Enemark scale (Table 5).
Furthermore, on defining the height of the bony bridge, there was
moderate agreement (kappa ¼ 0.526, p < 0.001) between the new
scale and the Enemark scale (Table 6).
A statistically significant positive correlation was reported be-
tween the new success scale and the closure of the space of a
missing or extracted lateral incisor (Table 7). A statistically signifi-
cant negative correlation was reported between the new success
scale and the age at surgery, the graft revision and the presence of
residual fistula (Table 7). No other statistically significant correla-
tions were detected.
4. Discussion
As mentioned above, plain radiographs provide insufficient or
even inaccurate data on the morphology of the repaired alveolar
cleft site. Bone height should not be the only success criterion (Lee
et al., 1995; Iino et al., 2005; Liu et al., 2016). A bone deficit in the
middle or apical part of the adjacent roots, due to the extent of the
nasal cavity, or a thin bony bridge may hinder orthodontic move-
ments or implant placement (Lee et al., 1995; Hynes and Earley,
2003; Iino et al., 2005; Semb et al., 2011; Suomalainen et al.,
2014). Computed tomography may be the solution, but there is
concern over the increased radiation dose (Rosenstein et al., 1997).
CBCT, which is widely used in oral and maxillofacial radiology,
manages to reduce radiation exposure, in line with the ALARA (as
low as reasonably achievable) principle (Oberoi et al., 2009;
Suomalainen et al., 2014; Stasiak et al., 2019). Scientific evidence
supports the application of CBCT in the cases in which its benefits
394 G. Kamperos et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 391e398

Table 1 Table 3
The new success scale for alveolar cleft repair, based on CBCT. The measurements Outcome evaluation according to the Bergland and Enemark scales.
were made in relation to the adjacent teeth.
Outcome evaluation n %
New success scale for alveolar cleft repair Bergland and Enemark scales

Bone H4. >3/4 of normal height Bergland scale

Height (H) H3. 1/2e3/4 of normal height Type І 14 30
H2. 1/4e1/2 of normal height Type ІІ 12 26
H1. <1/4 of normal height Type ІІІ 19 41
H0. no continuous bony bridge across the cleft Type ІV 1 2a
Bone W2. >1/2 of the width of the adjacent roots Enemark scale
Width (W) W1. <1/2 of the width of the adjacent roots Score 1 26 57
W0. no continuous bony bridge across the cleft Score 2 7 15
Nasal floor (N) N4. extent of the nasal floor up to the apical 1/4 of the Score 3 8 17
adjacent roots Score 4 5 11
N3. extent of the nasal floor up to 1/2 of the adjacent roots a
The sum is not 100% due to rounded percentages.
N2. extent of the nasal floor up to 3/4 of the adjacent roots
N1. extent of the nasal floor more than 3/4 of the adjacent
roots,
approaching the cementoenamel junction Table 4
N0. no continuous bony bridge across the cleft Outcome evaluation according to the new success scale.

Outcome evaluation n %
New success scale
Table 2
Patients’ demographics, presurgical, surgical and postsurgical parameters. Bone height
H4 23 43
Parameters n % Mean SD Range H3 14 26
Age at surgery 11.9 2.1 8.3e16.2 H2 4 8
Gender H1 11 21
Male 32 73 H0 1 2
Female 12 27 Bone width
Follow-up (years)/time of post-surgical CBCT 9.1 5.8 2e22 W2 35 66
Alveolar cleft W1 17 32
Unilateral 35 80 W0 1 2
Bilateral 9 20 Nasal floor
Cleft of the soft palate N4 45 85
Yes 35 80 N3 5 9
No 9 20 N2 1 2
Volume of deficit (cm3) 1.2 0.4 0.6e2 N1 1 2
Presurgical orthodontics N0 1 2
Yes 43 98 Total score
No 1 2 10 (total success) 19 36
Postsurgical orthodontics 9 (acceptable) 13 25
Yes 44 100 8 (compromised) 3 6
No 0 0 7 (unfavorable) 5 9
Canine eruption 6 (extremely unfavorable) 12 23
Yes 20 38 0 (total failure) 1 2a
No 33 62 a
The sum is not 100% due to rounded percentages.
Missing or extracted lateral incisor
Yes 40 75
No 13 25
Origin of graft postsurgical follow-up of alveolar cleft patients is recently
Iliac 42 95 increasing. The current study is among the largest such series (van
Mental 2 5
der Meij et al., 2003; Liao and Huang, 2015; Liu et al., 2015, 2016;
Form of graft
Particulate 33 75 Meazzini et al., 2016; Wang et al., 2016; Graillon et al., 2018). Of
Block 11 25 course, every consideration for further reduction of radiation
Graft revision exposure in these young patients should be made, such as selecting
Yes 3 7 the smallest field of view (FOV) possible for each specific case
No 41 93
(Suomalainen et al., 2014; Stasiak et al., 2019). In the present study,
Residual fistula
Yes 4 9 a 12  8 cm FOV was preferred in order to assess the condition of
No 40 91 the nasal cavity and the sinuses, as well. A smaller FOV may be
Outcome of unerupted canines adequate for evaluating only the alveolar process.
Spontaneous eruption 24 73
There are only a few CT studies attempting to set thresholds for
Orthodontically-assisted eruption 5 15
Not erupted 4 12 characterizing a good postsurgical outcome (Liu et al., 2015;
Restoration of missing or extracted lateral incisors Meazzini et al., 2016; Garib et al., 2017). Even those studies do
Preservation of space 21 53 not provide a single success scale that considers all dimensions of
Closure of space 14 35 the bony bridge. Liu et al. (2015) propose two separate scales for the
Under treatment 5 13a
evaluation of the height and the width of the bony bridge (Liu et al.,
a
The sum is not 100% due to rounded percentages. 2015). Suomalainen et al. (2014) calculated a cumulative score out
of each dimension (Suomalainen et al., 2014). In their study, a single
exceed the possible risks, thus enhancing diagnosis and treatment scale was formed, but it was not associated with the success of
planning (Wangsrimongkol et al., 2013). Cleft patients’ manage- alveolar cleft repair. The novel scale presented in this study is, to
ment is challenging and may benefit from such modern imaging our knowledge, the first that takes into consideration all di-
applications. The number of researchers using CT for the mensions of the bony bridge and provides a single threshold for
 G. Kamperos et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 391e398
Fig. 2. Representative cases evaluated using the new success scale: total score (bone
height e H, bone width e W, nasal floor e N). Reconstructed panoramic view (a),
representative coronal slice (b), axial slice (c).
successful results. Measurements were made in relation to the
adjacent teeth, which is a common practice for similar CT studies
(Iino et al., 2005; Trindade-Suedam et al., 2012; Wangsrimongkol
et al., 2013; Suomalainen et al., 2014; Liu et al., 2015, 2016; Wang
et al., 2016; Garib et al., 2017), as well as for the traditional scales
based on plain radiographs (Bergland et al., 1986; Enemark et al.,
1987; Long et al., 1995; Witherow et al., 2002; Russell et al.,
2016). The evaluation of bone height, bone width and nasal floor
shares similarities with the Enemark scale and the measuring
systems proposed by Wangsrimongkol et al. (2013), Liu et al. (2015)
and Garib et al. (2017) (Enemark et al., 1987; Wangsrimongkol et al.,
2013; Liu et al., 2015; Garib et al., 2017). The total score is calculated
in a way similar to that described by Suomalainen et al. (2014)
(Suomalainen et al., 2014).
The new scale has certain features that might prove useful in
clinical practice. First, the application is quite easy. Simplicity is of
great importance, as verified by the success of the Bergland scale, in
395
Fig. 3. Clinical cases evaluated using the new success scale: total score (bone height e
H, bone width e W, nasal floor e N). First case (successful): female patient with right
unilateral alveolar cleft, treated with iliac autograft at 14.9 years of age. Second case
(failed): female patient with bilateral alveolar cleft, treated with iliac autograft at 11.5
years of age (right side depicted). Presurgical examination: clinical image (a), pano-
ramic x-ray (b). Recall examination at the end of follow-up: clinical image (c),
reconstructed panoramic view from CBCT (d), representative coronal slice (e), axial
slice (f).
contrast to other, more complicated ones (Bergland et al., 1986;
Long et al., 1995; Witherow et al., 2002; Russell et al., 2016). Sec-
ond, the new scale provides accurate data on the three-dimensional
morphology of the repaired alveolar process (bone height, bone
width, nasal floor). Third, it sets a clear success threshold. Finally, it
can be applied in both mixed and permanent dentition, before or
after canine eruption. Early evaluation facilitates possible regraft-
ing. Nevertheless, there may be some weaknesses in the proposed
scale. The cost and radiation dose are increased, compared to plain
radiographs. Furthermore, the bone coverage of the adjacent teeth,
apart from the bony bridge, is not measured. On the contrary, the
SWAG scale provides a relative prognosis for regrafting based on
this finding (Russell et al., 2016).
The success of alveolar cleft repair in the present sample, ac-
cording to the Bergland and Enemark scales, is relatively low
compared to that in some studies (Bergland et al., 1986; Kalaaji
et al., 1996; Opitz et al., 1999; Jia et al., 2006; Semb et al., 2011).
This may be associated with the technique modifications intro-
duced and the gradual increase in experience of our department,
as analyzed by Theologie-Lygidakis et al. (2014) (Theologie-
Lygidakis et al., 2014). On defining success versus failure, there
was no perfect agreement between the new CBCT scale and the
traditional plain radiograph scales, suggesting that the new scale
provides additional, and maybe useful, data on the outcome. A
significant number of cases were defined as successful according
to the Bergland scale, and failed according to the new scale, and
vice versa. The Bergland scale requires a bone height of at least
three-fourths of normal height for successful results, but evaluates
only the cervical bone level. On the other hand, the new scale
requires a bone height of at least one-half of normal height for
successful results, assuming that bone width and nasal floor are
relatively normal. As for the Enemark scale, there was a clear
overestimation of the success of alveolar cleft repair and the
height of the bony bridge. Therefore, it is implied that plain
396 G. Kamperos et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 391e398

Table 5
Evaluation of the agreement between the new scale and the Bergland and Enemark scales, on defining success versus failure. Relative frequencies are summed up horizontally.

Bergland scale (%) Enemark scale (%)

Success (types І and ІІ) Failure (types ІІІ and IV) Success (scores 1 and 2) Failure (scores 3 and 4)

New scale (%) Success (total scores 9e10) 78 22 100 0

Agreement Not agreement Agreement Not agreement
Failure (total scores 0e8) 26 74 32 68
Not agreement Agreement Not agreement Agreement
kappa ¼ 0.511, p ¼ 0.001 kappa ¼ 0.718, p < 0.001

Table 6
Evaluation of the agreement between the new scale and the Enemark scale, on defining the height of the bony bridge. Relative frequencies are summed up horizontally.

Enemark scale (%)

Score 1 Score 2 Score 3 Score 4

New scale (%) H4 100 0 0 0

Agreement Not agreement Not agreement Not agreement
H3 50 50 0 0
Not agreement Agreement Not agreement Not agreement
H2 25 25 50 0
Not agreement Not agreement Agreement Not agreement
H1 0 0 60 40
Not agreement Not agreement Not agreement Agreement
H0 0 0 0 100
Not agreement Not agreement Not agreement Not agreement
kappa ¼ 0.526, p < 0.001

Table 7
Statistically significant correlations between the new success scale and certain parameters.

Parameters New success scale pa

Positive correlation Closure of space of lateral incisor Bone width 0.028

Success vs failure 0.011b
Negative correlations Age at surgery Success vs failure 0.023c
Graft revision Bone height 0.001
Bone width 0.001
Total score 0.007
Success vs failure 0.007
Residual fistula Nasal floor 0.013
a
Fisher's exact test (2-sided).
b
Chi-square test (2-sided).
c
Mann-Whitney U Test.

radiographs cannot evaluate bone height accurately, due to im-
aging problems.
Statistical analysis revealed few, but quite interesting, associa-
tions between the various parameters and the new success scale.
First, according to these findings, the closure of the space of a
missing or extracted lateral incisor increases mainly the width of
the repaired alveolar process, and not its height, as previously
suggested by Liao and Huang (2015) (Liao and Huang, 2015). Sec-
ond, increased age at surgery usually leads to worse results (Dempf
et al., 2002; Calvo et al., 2014). This is attributed to the lack of the
functional stress caused by the canine eruption into the graft. In the
present study, canine eruption had a positive but not statistically
significant influence on the success of alveolar cleft repair. Third,
graft revision is recognized, for the first time, as a negative prog-
nostic factor. Cases needing regrafting, due to wound infection and
graft resorption, are commonly challenging from the start: for
example, bilateral clefts or clefts with large oronasal fistulas. Re-
entry is even more difficult because of the poor quality of the soft
tissues. As a result, the outcome should not be expected to be
perfect. Finally, the presence of a residual fistula may indicate a
greater extent of the nasal floor toward the cementoenamel junc-
tion in the repaired alveolar process. The lack of further statistical
correlations is probably caused by the small sample of the present
study.
Despite the clear advantages of CBCT in the postsurgical
follow-up of alveolar cleft patients, it is still unknown whether a
success scale using CT could replace the traditional ones. More-
over, should such a scale be applied in every case, or it should be
reserved for special indications? It is generally agreed that dental
implant therapy requires three-dimensional imaging. On the
other hand, it is unclear whether orthodontic treatment planning
benefits from CT in alveolar cleft patients. Lee et al. (1995)
suggested that postsurgical axial CT scans were useful in diffi-
cult cases (Lee et al., 1995). Wriedt et al. (2017) evaluated the
diagnostic and prognostic value of presurgical CBCT on ortho-
dontic therapy (Wriedt et al., 2017). Even if a significant number
of treatment proposals changed when using three-dimensional
instead of two-dimensional records, statistical analysis showed
no essential differences. The authors commented that CBCT may
be justified in orthodontics only in selected alveolar cleft cases
and only as a supplement to a routine panoramic radiograph
(Wriedt et al., 2017). Nevertheless, the usefulness of possible
postsurgical CBCT was not assessed. Further research is neces-
sary in this field. The application of the proposed success scale
 G. Kamperos et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 391e398
by examiners of various specialties is necessary in order to
evaluate its potential value.
5. Conclusions
The novel success scale for evaluating alveolar cleft repair using
CBCT takes into consideration all dimensions of the bony bridge. It
provides information on the outcome of bone grafting that is
inaccessible by the traditional two-dimensional scales. Future
application is necessary for validation of its potential value.
Declaration of Competing Interest
The authors declare that they have no conflicts of interest.
Acknowledgements
This work was supported by a scholarship [G ZN 017-1/
2017e2018] from the Alexander S. Onassis Public Benefit
Foundation.
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