The orthodontist’s role in the

management of patients with cleft lip

and palate undergoing alveolar bone
grafting
John O. Wirthlin

Alveolar bone grafting (ABG) represents a major event in the treatment of

patients with cleft lip and palate. ABG can provide stability to the maxillary
arch thus preventing future collapse of the alveolar segments, provide
adequate bone for the periodontal health and support of the teeth adjacent to
the cleft, improve nasal esthetics by normalizing the piriform rim anatomy,
allow for closure of nasolabial fistulas, and improve some speech parameters
such as nasal air emission. It is critical for an orthodontist to understand the
pertinent considerations surrounding ABG as well as how orthodontic
treatment before and after the ABG can impact the overall result of the ABG.
This review article provides historical background on ABG and reviews
important considerations such as the timing of ABG, pregraft orthodontic
treatment, the use of postoperative splints, and the evaluation of ABG
results. (Semin Orthod 2017; 23:268–278.) & 2017 Published by Elsevier Inc.

Introduction lip and palate. As a key member of the cleft team

A
it is essential for an orthodontist to understand
lveolar bone grafting is one of the most
the pertinent issues surrounding this procedure
critical components during the recon-
and understand their role in achieving a suc-
struction of a patient with a cleft lip and palate.
cessful result.
Alveolar bone grafting can provide stability to the
Although the first successful alveolar bone
maxillary arch thus preventing future collapse of
graft was described over a hundred years ago in
the alveolar segments, provide adequate bone for
1914 by Drachter,3 there is still considerable
the periodontal health and support of the teeth
debate over many aspects of alveolar bone
adjacent to the cleft, improve nasal esthetics by
grafting, including surgical timing, orthodontic
normalizing the piriform rim anatomy, allow for
preparation prior to alveolar bone grafting, the
closure of nasolabial fistulas,1 and improve some
use of intra-oral splints after grafting, and the
speech parameters such as nasal air emission.2
manner to assess the success of the procedure.
While a successful alveolar bone graft can
Below we will examine each of this considerations
provide the above benefits, unsuccessful
in detail.
alveolar bone grafting often leads to tooth loss,
persistent nasal regurgitation, persistent nasal air
emission, and can complicate and compromise
future orthodontic and orthognathic treatment. Timing
Alveolar bone grafting can be considered a major Prior to the 1950s alveolar bone grafting was not
cross-road for the treatment of a patient with cleft consistently performed, thus no consensus had
formed concerning the ideal timing of the pro-
Department of plastic surgery, Texas Children's Hospital, Clinical cedure. By the 1960s primary alveolar bone
Care Center, Houston, TX. grafting, grafting that takes place at the time of
Address correspondence to John O. Wirthlin, DDS, MSD, Texas
the primary lip repair, became a “routine pro-
Children's Hospital, 6701 Fannin St, Clinical Care Center, 8th Floor,
Houston, TX 77030. E-mail: [email protected] cedure in nearly all cleft palate centers in the
& 2017 Published by Elsevier Inc.
world”.4 It was hoped that primary alveolar bone
1073-8746/12/1801-$30.00/0 grafting would not only eliminate the bony
http://dx.doi.org/10.1053/j.sodo.2017.05.003 deficiency, stabilize the maxillary arch, create

Seminars in Orthodontics, Vol 23, No 3, 2017: pp 268–278 268

 Orthodontist’s role in managing patients undergoing ABG 269

bony support for the dentition, and improve has become the most commonly accepted time
nasal esthetics, but some also postulated that period to perform alveolar bone grafting. A
primary grafting would stimulate future maxillary survey taken of ACPA teams in 2005 showed 90%
growth.5 By performing the alveolar bone graft at of the teams that responded to the survey per-
the time of the primary lip repair it also formed secondary alveolar bone grafting.15
eliminated the need for a separate surgical When comparing early, intermediate, and late
procedure with the associated anesthesia. secondary bone grafting, 78% reported
It was not long after the widespread accept- performing intermediate alveolar bone grafts
ance of primary alveolar bone grafting that between the age of 6 and 9.15
concerns were raised about the assumed benefits Although a range of chronological ages can be
of the procedure and possible unanticipated used by a team to determine when to perform
sequelae.6–8 By the 1970s, many centers had secondary alveolar bone grafting, the exact tim-
abandoned primary bone grafting amid growing ing should be patient specific. In reality, it is the
evidence showing maxillary hypoplasia in development of the dentition that drives the
patients who received primary alveolar bone decision and not chronological age. The goal
grafting.9,10 More recent inter-center studies should be to perform the graft early enough to
have also suggested maxillary growth restriction allow the erupting permanent dentition to have
in patients who have had primary alveolar bone good alveolar support, but wait as long as possible
grafting.11,12 Although not widespread, some to limit the possible negative side effects on the
cleft centers continue to perform primary bone growth of the maxilla.
grafts. Among the various reasons for the con- Several studies have shown that the success of
tinued use of primary alveolar bone grafting are alveolar bone grafting is increased if it is per-
the reduction in the number of future surgical formed prior to the eruption of the maxillary
procedures, possible improved periodontal sup- canine on the clefted side.16–19 If alveolar bone
port of the teeth adjacent to the alveolar cleft grafting is postponed until after the eruption of
when compared to grafting in the mixed or the entire permanent dentition the position of
permanent dentition,13 and the ability to provide the erupted canine often decreases surgical
a bone graft to patients at the same time as the lip access and is difficult to move orthodontically
repair if poor follow-up is anticipated and a bone without exposing the root surface into the
graft procedure would be unlikely at a later date.
The centers that abandoned primary alveolar
bone grafting often relied heavily on prostho-
dontic restoration to compensate for the poor
dental outcomes that occurred without alveolar
bone grafting.
In 1972, Boyne and Sands first advocated
secondary bone grafting.14 Secondary alveolar
bone grafting is performed at any time after the
primary lip and palate repair and can be divided
into three broad groups based on timing. Early
secondary alveolar bone grafting is generally
performed in the primary dentition, intermed-
iate secondary alveolar bone grafting is generally
performed during the mixed dentition, and late
Figure 1. This patient with a complete unilateral cleft
secondary alveolar bone grafting occurs in the lip and palate did not receive an alveolar bone graft
permanent dentition. Secondary alveolar bone prior to the eruption of the canine on the cleft side. As
grafting was meant to provide the benefits of can be seen, the location of the canine now severely
alveolar bone grafting that prosthetic could not compromises access for the surgical procedure and
without the maxillary hypoplasia that was often closure of the gingival flaps. The position, lack of
space, and knowledge that the mesial surface of the
seen with primary alveolar bone grafting. root is only covered by a thin shell of alveolar bone
Although it took some time to gain widespread make orthodontic movement of this tooth difficult
popularity, intermediate secondary bone grafting without creating root exposures.
270 Wirthlin

Figure 2. This patient with a complete unilateral cleft

lip and palate did not receive an alveolar bone graft
prior to the eruption of the canine on the cleft side. As
can be seen, the location of the canine now severely
compromises access for the surgical procedure and
closure of the gingival flaps. The position, lack of
space, and knowledge that the mesial surface of the Figure 3. Early secondary alveolar bone grafting prior
root is only covered by a thin shell of alveolar bone to the eruption of the central incisor on the cleft side
make orthodontic movement of this tooth difficult may be indicated in this patient due to the severely
without creating root exposures. ectopic path of eruption of the central incisor on the
cleft side. If grafting is delayed until after the eruption
of the central incisor it is likely the position of this
alveolar cleft (Figs. 1 and 2). It is for the above tooth will severely compromise access to the surgical
reason that most centers advocate intermediate site and will be very challenging to move orthodonti-
secondary alveolar bone grafting when the cally without creating a root exposure into the cleft.
unerupted canine has 1/2 to 2/3rds of its root
developed. It has also been noted that when a
viable lateral incisor is present adjacent to the not completed and the central incisor erupts in a
alveolar cleft, the root development of the manner that obstructs surgical access and cannot
unerupted lateral incisor should be used as a be easily moved orthodontically the future
gauge to determine the timing of the alveolar periodontal status of this tooth and success of
bone graft and not the canine. Some centers also the alveolar bone graft may be compromised.20
advocate alveolar bone grafting prior to the This is the same logical that many apply to the
eruption of the central incisor nearest the cleft goal of grafting prior to the eruption of the
site.20 This would be considered early secondary maxillary canine or an unerupted lateral incisor,
alveolar bone grafting. These centers have but many ignore when considering the central
reported better periodontal support for the incisor. A second relevant consideration when
central incisor20 vomer and a larger volume comparing early and intermediate secondary
of successfully grafted alveolar bone when alveolar bone grafting is the ability to comply
compared to intermediate secondary alveolar with pregraft orthodontics. While most children
bone grafting.21 When examining early can comply and tolerate orthodontic treatment
secondary alveolar bone grafting there is some in the mixed dentition, many children in the
debate concerning growth. Some studies have primary dentition cannot. If the patient is not
shown some degree of maxillary hypoplasia22 cooperative and pregraft orthodontics is consi-
while others have shown no growth restriction dered to be critical, intermediate secondary
with early secondary alveolar bone grafting23 alveolar bone grafting may be a better choice
when compared to intermediate secondary than early secondary alveolar bone grafting.
alveolar bone grafting. Although secondary alveolar bone grafting is
When comparing intermediate to early sec- currently the most commonly performed timing
ondary bone grafting there are two more of alveolar bone grafting, gingivoperiosteoplasty
importance variables to take into consideration. (GPP) is another variation of an alveolar bone
The first is the eruption path of the central graft used routinely by some cleft teams. This
incisor. If it is anticipated that the central incisor procedure is performed when the edges of the
will erupt ectopically toward the cleft, early alveolar cleft are in close proximity to each other
grafting may be indicated (Fig. 3). If grafting is and is performed at the time of the primary lip
 Orthodontist’s role in managing patients undergoing ABG 271

growth, dentition present adjacent to the cleft,

timing of dental eruption, path of dental erup-
tion, and ability to comply with pregraft ortho-
dontics. Each one of these factors should be
considered for each patient. Because of this there
will be always be variability in the ideal timing for
each individual patient.

Pregraft orthodontics
Another important, yet controversial, factor to
consider in regards to alveolar bone grafting is
the use of pregraft orthodontics to prepare the
Figure 4. Prior to the primary repair this patient
received presurgical orthopedics that molded the patient for surgery. In many centers maxillary
edges of the alveolar segments into close proximity expansion with or without orthodontic brackets
allowing for GPP. are used prior to the grafting procedure.
Although many centers follow this protocol and
repair. This proximity of the alveolar processes many assume pregraft orthodontics to be
may be the nature of the initial deformity or due essential to a successful alveolar bone graft,
to presurgical orthopedics such as NasoAlveolar recent publications are not as conclusive.
Molding (NAM)24 (Fig. 4). In a GPP, flaps are In 2000, a retrospective study examined 64
elevated at the anterior edges of the alveolar canines that spontaneously erupted after secon-
segments at the time of the primary lip repair and dary alveolar bone grafting. Of those 64 canines,
then connected. By doing this, the clefted 44 were in patients who received pregraft ortho-
alveolus is bridged by gingival tissue and dontics and 20 were in patients that did not receive
creates “a gingivoperiosteal tunnel that facili- pregraft orthodontics. Furthermore, 68% of the
tates bone healing through guided tissue canines examined in the patients who had pregraft
regeneration (GTR) without the need for bone orthodontics achieved normal interdental bone
grafting and its associated donor site mor- levels while 4% of the canines achieved no bony
bidity”.25 Some believe that a GPP retains bridge, a complete failure of the graft. Com-
many of the benefits of primary alveolar bone paratively, 65% of the patients who did not have
grafting without the midface hypoplasia26,27 pregraft orthodontics achieved normal interdental
often seen with primary alveolar bone grafting. bone levels while there were zero complete fail-
Other published studies on GPP have suggested ures.18 This led the investigators to the conclusion
similar midface growth restriction as is seen in that bone levels in the group that received
primary alveolar bone grafts.28,29 pregrafting expansion were no better than when
The timing of an alveolar bone graft is pregraft expansion was not performed.18 In 2013,
probably the most important decision sur- a 10-year follow-up examined the outcomes of
rounding this critical surgical procedure. secondary alveolar bone grafting and found the
Although much has been learned from exam- lowest success in the group that had pregrafting
ining past results, there still exists much debate orthodontics.19 A recent multicenter investigation
over the ideal timing of the procedure. While examining the outcomes of secondary alveolar
intermediate secondary bone grafting in the bone grafting suggested that the effect of pregraft
mixed dentition is the most common time to orthodontics on alveolar bone graft outcomes
perform the procedure, primary alveolar bone appears to be equivocal.30
grafting, early secondary alveolar bone grafting, At face value these studies appear to suggest
and GPP all have various supporters. The reason there are no benefits to pregraft orthodontics
for these incongruent treatment protocols likely prior to alveolar bone grafting and that pregraft
stems from the multitude of factors that can orthodontics may even reduce the likelihood of a
influence this decision, such as initial cleft successful graft. Selection bias is an obvious
anatomy, access to presurgical orthopedics, problem with these studies that prevents one from
anticipated follow-up care, anticipated maxillary reaching these conclusions. It may be that the
272 Wirthlin

most difficult cases are often the ones being

selected to have pregraft orthodontics. Also, the
broad variety of different types of pregraft
orthodontics along with the variety of dentoal-
veolar deformities also makes it difficult to advo-
cate completely against pregraft orthodontics.
To investigate the relationship between
alveolar bone graft success and pregraft ortho-
dontics one must consider the factors that can
influence a successful graft. Logic could suggest
that pregraft expansion may increase the diffi-
culty of the procedure by increasing the volume Figure 5. As can be seen from the initial panoramic
of the alveolar cleft needing to be grafted. Long radiograph the central incisor adjacent to the cleft
erupted in a severely rotated position. Brackets were
et al.31 investigated this variable and concluded placed on this tooth prior to grafting and although the
that the width of the cleft prior to secondary root was not tipped a root exposure resulted due to the
alveolar bone grafting “seemed to have little correction of the rotation.
bearing” on the success of the alveolar graft. A
retrospective study in 2000 investigated the
factors that lead to a successful alveolar bone this may occur at times, it is not a primary goal of
graft found that successful bone grafting seems to pregraft orthodontics. Often patients prior to
not depend on the initial size of the cleft, but alveolar bone grafting exhibit maxillary hypo-
instead depended on the presurgical amount of plasia and a resulting Class III sagittal relation-
bone supporting the teeth adjacent to the cleft.32 ship. Correcting the transverse crossbites in this
Interestingly, the bone support of the teeth sagittal position would lead to over expansion of
adjacent to the cleft can indeed be effected by the maxilla. Maxillary expansion is indeed
pregraft orthodontics. If orthodontics brackets commonly used prior to alveolar grafting but not
are placed on the teeth adjacent to the cleft, with the goal of eliminating crossbites, but to
resorptive compressive forces can be placed on normalize the maxillary arch form. Due to the
the thin shell of alveolar bone adjacent to the tension from the palatal scar, most patients with
cleft and cause root exposure of the teeth cleft lip and palate have some degree of maxillary
adjacent to the cleft, thus reducing the amount constriction. This constriction is also often
of presurgical bone support of these teeth. If asymmetrical, particularly in a patient with uni-
brackets are placed on the teeth adjacent to the lateral complete cleft lip and palate. In patients
cleft great caution must be exercised to avoid with unilateral cleft lip and palate, the lesser
creating root exposures. To avoid this from segment almost invariably will be constricted to a
occurring, it is common to place the bracket greater degree than the greater segment. This
on the crown of the tooth adjacent to the cleft in creates not only a constricted maxillary arch form
an atypical location to avoid any mesial or distal but an asymmetric maxillary arch form. Expan-
tipping of the tooth roots. Often overlooked sion prior to bone grafting present an oppor-
however, are the forces placed on the root of the tunity to normalize this constricted, often
tooth in the first degree when an ectopic tooth is asymmetric, arch form before the maxillary arch
rotated. These forces are more difficult to is united. Although expansion can be performed
control by simple atypical bracket placement after alveolar bone grafting to correct any
and may lead to root exposures (Figs. 5 and 6). residual constriction, it can be more challenging
With the understanding that pregraft ortho- and in particular more difficult to correct any
dontics must be performed with great care to skeletal asymmetries.
ensure improved graft outcomes, if it is decided Once it has been determined that an arch
to perform pregraft orthodontics it is critical to form discrepancy exists one must decide how to
define the goals of pregraft orthodontics. Many correct this discrepancy. Again, several options
believe the purpose of orthodontics prior to exist. Although some type of maxillary expander
alveolar bone grafting is to eliminate transverse is the most commonly used method, traditional
crossbites with maxillary expansion. Although orthodontic appliances may also be able to
 Orthodontist’s role in managing patients undergoing ABG 273

Figure 7. A quad helix can help correct an arch form

asymmetry and constriction as seen in these pre- and
postexpansion photos. Extraction of the primary
canine on the lesser segment at least 1 month prior
to grafting will also greatly improve access for the
alveolar bone grafting procedure by creating a wide
area of keratinized gingival tissue adjacent to the cleft
to facilitate closure.

advantages of these types of expanders is the

ability to differentially expand anteriorly more
than posteriorly. Often this is the type of
expansion that is needed in patients with a cleft
alveolus to correct their arch form discrepancy.34
A unique variation of the traditional quad helix is
the reverse quad helix.35 By reversing the quad
helix differential anterior expansion is favored.
The major disadvantage of these slow maxillary
expansion appliances is the need for appliance
removal to reactivate.
Rapid palatal expansion also can be used
Figure 6. As can be seen from the initial panoramic to correct the arch form discrepancies found
radiograph the central incisor adjacent to the cleft
erupted in a severely rotated position. Brackets were in patients with cleft lip and palate. Many
placed on this tooth prior to grafting and although the
root was not tipped a root exposure resulted due to the
correction of the rotation.

accomplish the task. When using orthodontic

appliances to correct the arch form in a patient
with an alveolar cleft, caution must be exercised
when placing brackets on teeth adjacent to the
alveolar cleft, as stated above. It is also assumed
by most that arch wire expansion is mostly a
dental correction and not a skeletal correction,
although some feel skeletal arch development is
possible with orthodontic appliances alone.33 Figure 8. A quad helix can help correct an arch form
If an expander is chosen as the method to asymmetry and constriction as seen in these pre- and
correct the arch form discrepancy many types of postexpansion photos. Extraction of the primary
expanders exist, each with its own set of advan- canine on the lesser segment at least 1 month prior
to grafting will also greatly improve access for the
tages and disadvantages. Many practitioners alveolar bone grafting procedure by creating a wide
prefer slow maxillary expanders, such as a W arch area of keratinized gingival tissue adjacent to the cleft
or a quad helix (Figs. 7 and 8). One of the major to facilitate closure.
274 Wirthlin

When assessing arch form in patients with cleft

lip and palate, it is most common to discrep-
ancies in the transverse dimension. However,
patients born with bilateral cleft lip and palate
occasionally have severe arch from discrepancies
in the vertical and anterior-posterior dimension
when evaluating the premaxilla. In these patients
a decision needs to be made regarding how to
correct this discrepancy. If the discrepancy is
severe premaxillary repositioning may be indi-
cated as part of the alveolar grafting procedure.
Figure 9. Fan Hyrax expanders produce preferential During premaxillary repositioning an osteotomy
anterior expansion with similar mechanics and activa- is performed above the premaxilla on the vomer.
tion to traditional Hyrax expanders. However, con- The premaxilla can then be skeletally reposi-
striction posterior to the point of rotation is possible tioned with the aid of a surgical splint. This splint
creating transverse crossbites in the 2nd molar region. can then be retained after the procedure to
stabilize the premaxilla during healing.
practitioners are more comfortable with these Besides arch form correction another goal of
devices compared to slow expanders and once pregraft expansion is to create or improve sur-
the appliance is cemented there is no need to gical access. This may be accomplished by max-
remove the appliance to reactivate. Many prac- illary expansion, orthodontic appliances, or by
titioners also feel that rapid expansion creates dental extraction. If a permanent tooth has
more skeletal expansion than dental expansion erupted in a manner that restricts access to the
when compared to slow maxillary expanders, surgical site the tooth may need to be moved.
although this has been questioned by some.36 A This can be done with expansion, but severely
major disadvantage of traditional Hyrax and ectopic teeth usually need some form of ortho-
Haas expanders is that they do not allow for dontic appliances. As emphasized above, ortho-
preferential anterior expansion. In some cases dontically moving a tooth adjacent to an alveolar
this preferential anterior expansion may not be cleft can be a risky proposition and great care
needed and a traditional Hyrax or Haas must be taken to avoid exposing root surfaces
expander may be adequate, but this is often into the alveolar cleft. If it is anticipated that a
not the case. If preferential anterior expansion is tooth adjacent to the alveolar cleft may erupt in a
required a fan rapid palatal expander can be direction that will restrict access to the surgical
used. These can be fabricated as either a Hyrax site it may be prudent to attempt to graft prior to
or a Haas type of expander. These expanders the eruption of that tooth (Figs. 1 and 2). By
retain the advantages of rapid palatal expanders grafting prior to its eruption you can more easily
while allowing for preferential anterior correct the ectopic eruption once it erupts
expansion. Unfortunately, it has been noted through the graft and is surrounded by adequate
that although these fan Hyrax expanders alveolar bone.
preferentially expand anteriorly they also tend If a primary tooth is limiting access, the sol-
to constrict posteriorly37 leading to possible ution is much more simple. By extracting these
posterior crossbites and possibly bony primary teeth surgical access can be greatly
interferences in the pterygoid area during improved. If the extraction is performed at least a
expansion38 (Fig. 9). A unique double-hinged month prior to the alveolar bone graft the gin-
maxillary Hyrax fan expander has been advo- gival tissue surrounding the extraction can heal
cated by some as a solution to the posterior and provide robust gingival tissue in the area of
constriction of typical fan Hyrax expanders.38 the graft facilitating flap closure.
Another disadvantage of rapid maxillary
expanders is they tend to be more bulky than
Postoperative splints
slow maxillary expanders and can be more
challenging for patient to adapt to in regard to Although the literature is lacking in regard to
comfort, eating, and speech. discussion and examination of postoperative
 Orthodontist’s role in managing patients undergoing ABG 275

intra-oral splints for alveolar bone grafting, some postoperative radiograph.40 The postoperative
center have made this part of their protocol. radiographs were taken 4 months after the
These intra-oral splints usually are horseshoe grafting procedure. A score of 1 represents a
shaped and cover the maxillary occlusal surfaces. bony fill of 475%, a score of 2 represents a bony
Appropriate relief is also provided in the area of fill of 50–75%, a score of 3 represents a bony fill
the graft. Their construction can range from of o50%, and a score of 4 represents a complete
simple thermoplastic retainers to bonded acrylic failure.
splints to acrylic splints retained with various The Chelsea scale was developed to provide
retention clasps. The proposed benefits of these more information concerning the location of the
splints include retention of the pregraft arch bony fill than either the Bergland or the Kin-
form change, protection of the surgical site, and delan scale. The Chelsea scale uses a 0–8 point
stabilization of the premaxilla in the case of bone scale to define the amount of bone present, with
grafts in patients with complete bilateral alveolar 0 representing a complete failure and 8 repre-
clefts. In contrast, these splints can lead to poor senting complete fill. The scale then assigns one
hygiene and add another level of complexity to of 6 letters (A–F) to the numerical score to
the alveolar bone graft procedure. indicate the location of the successfully
grafted bone.
Recently, another method for evaluating the
Evaluation of results
results of alveolar bone grafts was validated. The
Ideally alveolar bone grafting would restore the SWAG (standardized way to assess grafts) scale30
bone in the cleft area to a mirror image of the not only evaluates the amount of fill and the
nonclefted side and close all soft tissue fistulas. location of the bone, but also provides an
Unfortunately, these ideal results are not always evaluation of the presence or absence of
achieved. Therefore it becomes important to be alveolar bone on the teeth adjacent to the cleft
able to assess the result of the alveolar bone graft in areas were a bony bridge did not form. This
in an objective consistent manner and be able to assessment of the periodontal status of the teeth
use that information to make clinic decisions. adjacent to the cleft in the area of no bony bridge
One of the first and most popular manners to is critical in making the clinical decision whether
assess the success of an alveolar bone graft is the regrafting is indicated.
Bergland scale.16 Originally the Bergland scale Although each one of these scales represents
used periapical radiographs to assess the bone fill an evolution towards a better way to assess the
after alveolar bone grafting, although panoramic results of an alveolar bone graft, each one still has
radiographs have also been used.39 The scale limitations. The interrater and intrarater reli-
rates the bone fill on a roman numerical scale ability for each of these scales is less than
from I to IV with I having a nearly normal desired,41 although the SWAG scale is reported
interdental bone fill, II indicates 3/4 fill, III is less to have the best reliability with an interrater
than 3/4 fill, and IV is a complete lack of bony reliability of 0.606 and intrarater reliability of
fill. Although this scale provides a simple and 0.760. The two-dimension nature of each of these
objective manner of assessment one of its major scales is also presents limitations. While using
limitations is the need for a fully erupted canine. two-dimensional radiology allows for the wide-
This requirement postpones the time of spread use of these scales due to the relatively
evaluation of the bone grafts unless a late easy access to two-dimensional radiographs,
secondary bone graft was performed. This important information can be missed when
postponement limits the Bergland scale's ability assessing alveolar bone grafts in two dimensions.
to help make clinical decisions in a timely Although some preliminary assessments of
manner. alveolar bone grafting using three-dimensional
The Kindelan scale was developed in response imaging have been examined,42–45 no widely
to the inability of the Bergland scale to provide accepted three-dimensional scale has been
timely assessment of the alveolar bone graft. This developed. The GAND (gap, arch, nasal, and
scale compares preoperative and postoperative dental parameters) classification is a newly
radiographs and rates the success of the bone developed method used to determine the mor-
graft based on the percentage of fill in the phology of the alveolar defect in a patient with
276 Wirthlin

unilateral cleft lip and palate46 using cone beam placement, the tooth can be extracted just prior
computed tomorgraph (CBCT). While this to regrafting and the dental implant can be
classification has the advantage of assessing placed shortly after the graft has healed. In this
the defect in three dimensions, its intraob- way, the success graft will not atrophy before
server reproducibility range of 0.29–0.92 and implant placement can be performed. The
its interobserver agreement range of 0.29–0.91 decision to recommend a regrafting procedure is
highlights some of the challenges of assess- not to be taken lightly. The repeated anesthesia,
ing alveolar defects using three-dimensional postoperative pain, and expense should only be
radiology. recommended if an improved result can be
Although objective scales are important in reasonably anticipated.
assessment of alveolar bone grafts, the more Alveolar bone grafting is a critical component
important consideration in the evaluation of of the reconstruction of patients with cleft lip and
alveolar bone grafts is whether to recommend palate. There are many decisions surrounding
regrafting. To be able to make this decision the this event that must be carefully examined. An
goals of grafting must be understood, along with orthodontist treating these patients must be able
the reasonable expectations for improvement if to clearly understand the ramifications of these
regrafting were to be performed. For example, a decisions and understand how the clinical
residual defect above the apices of the teeth orthodontic decisions that are made can sig-
should not lead to regrafting since the primary nificantly affect the success or failure of this
goal of support the dentition has been accom- procedure.
plished. Perfect alveolar anatomy may not be
necessary for a graft to accomplish its primary
goals. The SWAG scale also highlights a critical
consideration when making recommendations References
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bony bridge but the adjacent tooth roots are Surgery—Michael Miloro, G.E. Ghali, Peter Larsen, Peter Waite
covered with bone, one could reasonably expect —Google Books. London: BC Decker inc; 2004.
additional bone result from regrafting. Con- 2. Bureau S, Penko M, McFadden L. Speech outcome after
versely, if an area of the cleft that is lacking a bony closure of oronasal fistulas with bone grafts. [discussion
1413-4]. J Oral Maxillofac Surg. 2001;59(12):1408–1413
bridge also has root exposures of the adjacent [discussion 1413-4].
teeth, there would not be any reason to believe 3. Coots BK. Alveolar bone grafting: past, present, and new
that a repeat graft would result in additional bony horizons. Semin Plast Surg. 2012;26(4):178–183.
fill unless these periodontally compromised teeth 4. Koberg WR. Present view on bone grafting in cleft palate.
are extracted prior to regrafting. (A review of the literature). J Maxillofac Surg. 1973;1(4):
185–193.
Even if regrafting is needing it may be nec- 5. Wood BG. Control of the maxillary arch by primary bone
essary to postpone the attempted regrafting. If graft in cleft lip and palate cases. Cleft Palate J. 1970;7:
lack of postoperative compliance was considered 194–205.
to be a significant factor in the failure of the graft 6. Pruzansky S. Pre-surgical orthopedics and bone grafting
for infants with cleft lip and palate: a dissent. Cleft Palate J.
it may be necessary to postpone the graft until
1964;1(2):164–187.
improved compliance can be expected. Also, if a 7. Davies D. The radical repair of cleft palate deformities.
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