alveolar bone grafting

Introduction
 The successful treatment of patients
suffering from complete clefts of the lip
and palate requires a continuous
interdisciplinary therapy from birth until
early adulthood, which involves the
application of all available operative and
conservative procedures for treatment.
 The osseous closure of the alveolar cleft,
is required for the formation of a regular
upper dental arch, occupies a special
position within the whole concept of cleft
lip and palate therapy.

Alveolus Means Trough
(Latin Word); Trough
Containing Tooth Buds.

 Various Forms of Cleft Alveolus
 Cleft between laterals & canine (most
common)Tessier classification: No.4
(Tessiers, 1976)
 Cleft between centrals& Laterals
Tessier No.3 cleft
 Between centrals Tessier No.0 cleft
 More distally in the maxillary arch
Tessier No.5& No.7

History
 In 1901 – Von Eiselberg: Used pedicled flap (bone of little
finger) to fill alveolar cleft.
 In 1908 – Lexur: Free bone graft in cleft
 1914 – Drachter: Ist successful bone graft using tibial bone
and periosteum.
 1931 – Veau: Classification of cleft & attempted tibial bone
graft in alveolar cleft.
 1950 – Schmid: Successful ABG using iliac bone graft
 1955 – Johanson & Nordin: Primary ABG using tibial bone
in a stage procedure lip, palate, alveolus – closure by 1 yr.
of age.

 1960 – Schuchardt & Pfeifer: Primary ABG using rib graft
at the time of lip closure.
 1964–Pruzansky: Bone grafting should be delayed until
after eruption of permanent dentition
 1968–Jolley: Detrimental effects of early bone graft on
maxillary growth
 1972–Boyne&Sands: Protocol for secondary ABG
 1983–Wolfe et al: Favourable result with calvarial bone
 1987–Nique&Fonseca: ABG with allogenic bone

Developmental Anatomy
of
Alveolar Bone Premaxilla is a separate skeletal unit
(Moss )
 It develops from median nasal process
 Fusion of premaxilla with maxilla (at
Canine region)
 Starts 8th week in utero

PHARYNGEAL ARCHES
 Pharyngeal arches developes in the 4TH
and 5TH week.
 5 Pharyngeal arches
 Each arch contains cartilagenous muscular
and nerve components
 Pre maxilla and maxilla developes from 1st
arch

 At about24 days – 1st arch –maxillary
and mandibular process
 At about 28 days – lateral medial and
fronto nasal process
 Formation of middle portion of lip
upper and portion of maxilla and
primary palate

 At Birth
 Premaxilla remains separate from maxilla
by suture
 Closure of suture starts from 6-7 years of
age
Site of active osteogenesis
 Antero Posterior Development of
Premaxilla influenced by
 Intrinsic activity of membrananous bone
 Vomer - premaxillary suture
 Nasolabial muscles
 Tongue Posture & Function
 Tooth development

 Cleft Alveolus due to
 Failure of fusion of MNP &
maxillaryprocess
 Ossification centres in the premaxilla &
maxilla cannot migrate & fuse cause cleft
alveolus
 Vertical growth still active upto 9-10
years
 Transverse & AP Growth 95%
Completed at 8yrs.

Derivatives of the first pair of
the six pharyngeal arches
Maxillary prominence
Mandibular prominence
Facial development

Aetiology
 Hereditary
 Environmental

 Hereditary
 Less than 40% of cleft lip & palate are
of genetic origin
 Unaffected parents with a child who
has a cleft have a chance of (4.4%) a
second child with cleft
 If one parent has a cleft there is 3.2%
chance that first born will have a cleft.

 Environmental
 Infection (Rubella & Toxoplasmosis)
 Drugs – steroid, BZD, anticonsulsants
 Smokers

Incidence of Cleft
 1:750 births in USA
 Caucasians 1:1000 births
 African American 1:2000 births
 Asians 1:500 births
 Isolated cleft palate 1:2000 births
 Isolated cleft lip : 32%
 Lip & palate 68%
 Palate 2:1 :
 Side - Left : Right: Bilateral Þ 6:3:1

Treatment Goals and
Objectives
 Patient may Complaints of
 Food or fluid coming out of their nose
 Inability to blow balloon / suck a straw
 A persistent smell / discharge from nose
 Poor speech
 Inability to clean their teeth in cleft area
 Decayed / deformed teeth in cleft area
 Missing / extra teeth in cleft area
 Lack of bone support for teeth in cleft
area
 Poor alignment of teeth

 Mobility & overgrowth of premaxilla in
bilateral case
 Lack of support for the ala, base of the
nose & lip (Columella in bilateral case)

Rationale for Closure of Cleft
Alveolus
 To provide stability for maxillary arch
 Mainly in mobile premaxilla – bilateral
case
 To provides room for the canine and
lateral incisors to erupt into the arch into
stable alveolar bone and maintains bony
support of teeth adjacent to the cleft.
 To close oronasal fistula
 To construct pyriform rim & to provide a
better nasal symmetry
 To prevent inferior turbinate prolapse into
cleft

 Establishment of functional nasal airway
 To support accurate nasolabial
reconstruction
 Periodontal support for teeth lining the
cleft
 Oral & dental health improved
 Speech improved
 Improved orthodontic result
 Provide bony support for implant
placement

Timing of ABG
 Primary (0–2.5 years, usually at the
time of lip repair)
 Early secondary (2–5 years, before
the eruption of permanent incisors)
 Secondary (6–13 years, before the
eruption of the permanent canines)
 Late (> 13 years, after the eruption of
the permanent canines)

Primary ABG
 primary alveolar bone grafting as that
which is performed simultaneously
with lip repair
 any grafting that is performed at less
than 2 years of age is considered
primary grafting.
 primary grafting as grafting that is
performed before the palate is
repaired.

 Primary grafting performed at the time
of lip repair has failed to result in
acceptable outcome.
 Long-term studies show
◦ abnormal maxillary development with
maxillary retrognathia,
◦ concave profile,
◦ increased frequency of crossbite
compared with patients without grafts.

 Primary grafting performed after the
closure of the lip and before the
closure of the palate has proven
successful in a limited number of
centers when a very specific protocol
is followed.
 Eppley B. Alveolar cleft bone grafting (part 1): Primary bone
grafting. J Oral Maxillofac Surg 1996;54:74–82.
 11. Rosenstein SW. Early bone grafting of alveolar cleft
deformities. J Oral Maxillofac Surg 2003;61:1078–81.

 Advantage
 Early maxillary arch stabilization
 Improved arch form with out collapse
 Teeth adjacent to cleft erupt into grafted
bone.
 Disadvantage
 Maxillary growth affected(Sagittal &
Transverse Growth )
 Compensatory changes in mandible
 increased lower facial height

Reasons for Maxillary Growth
Disturbance
 Disruption of vomer – premaxillary
suture
 Extensive mucoperiosteal stripping
 scar formation
 Vomerine flap disruption

Early Secondary ABG
 2 – 6 years of age
 To provide support for eruption of
laterals
Disadvantage
 Significant transverse growth and
sagittal growth may be affected
 Literature not support the early
secondary grafting

Secondary
ABG
 9-11 years
 most commonly done before eruption
of canine
 When ½ to 2/3rd of canine root has
formed
 Only vertical growth remains at this
age.
 Physiological migration &
spontaneous eruption through grafted
bone observed.

 Rationale for grafting and for timing of grafting
during this time period include the following:
 Minimal maxillary growth after age 6 to 7
years
 The effect of grafting at this time will result in
minimal to no alteration of facial growth
 Cooperation with orthodontic and
perioperative care is predictable.
 The donor site for graft harvest is of
acceptable volume for predictable grafting with
autogenous bone

 Bone volume may be improved by
eruption of the tooth into the newly
grafted bone
 Grafting during this phase allows
placement of the graft before eruption of
permanent teeth into the cleft site - one
of the primary goals of grafting.

 Factors Contributing to timing of
Grafting During the mixed dentition
 Dental age vs chronologic age
 Presence and position of the lateral
incisor
 Degree of rotation/angulation of the
 central incisor
 Trauma/mobility of premaxillary segment
 (bilateral clefts)
 Size of the patient and of the cleft
 Occlusion
 Need for adjunctive procedures
 Social issues

 The graft be determined on the basis of
dental rather than chronologic age.
 If a lateral incisor is present and appears
to be well formed, earlier grafting may be
beneficial
 If the lateral incisor is located in the
posterior segment, earlier grafting may
be necessary to preserve the lateral
incisor

 The maxillary permanent central incisor will
often erupt in a rotated and angled position If
a decision is made to rotate these teeth into
alignment, it may be necessary to graft the
alveolar defect prior to this orthodontic tooth
movement
 Large defects, later grafting is often better, to
wait for growth of the patient and orthodontic
alignment of the cleft segments.
 Patients are often evaluated for
velopharyngeal incompetence, minor
esthetic revision of the nose or the lip, and
pressure-equalizing tubes for otitis media

Late Secondary Grafting
 Patients older than12 years of age
who undergo grafting have been
reported to have decreased success
when evaluated using the Bergland
scale, loss of osseous support of teeth
adjacent to the cleft, and increased
morbidity.

Pre Vs Post surgical
orthodontics
 Controversy exists regarding the use of
orthopedic expansion of the cleft
segments and the relationship between
expansion and grafting
 Most authors prefer presurgical
expansion because of less resistance,
improved access to the cleft for closure
of the nasal floor, better postoperative
hygiene, and less chance of reopening
the oronasal fistula

 Orthodontic movement of the erupted
teeth adjacent to the cleft is another
controversial topic
 Some authors suggest that aligning
the teeth adjacent to the cleft
produces better hygiene and an
improved result

History & Physical
Examination
Focused examination on:
 Any previous repair
 Oro nasal fistula
 Alar support
 Size of alveolar defect
 Mal positioned teeth in cleft region
 Alignment / cross bite of teeth
 Position & mobility of premaxilla
 Adequacy of soft tissue for tension free
closure
 Oral hygiene

Radiographic Evaluation
 OPG
 Occlusal view
 Peri apical view

Pre Surgical Preparation of a
Patient
 The Premaxillary Segment in bilateral
case stabilized by arch wire, Since
mobile premaxilla will cause the grafted
bone fail to consolidate.
 Oral Hygiene Prophylaxis
 Ortho treatment -Correction of cross
bite & alignment of arch

 Supernumerary or Retained Deciduous
teeth in cleft area should be removed
atleast 6 – 8 week before surgery to
ensure adequate width & continuity of
soft tissue
flaps.

Treatment options for cleft
alveolus
 Bone grafting
 Gingivo periosteoplasty
 Distraction osteogenesis

OPTIONS FOR ABG
 AUTOGENOUS
◦ ILIAC BONE
◦ RIB
◦ TIBIA
◦ CALVARIUM
◦ SYMPHYSIS
 ALLOPLASTIC
 ALLOGENIC

CANCELLOUS BONE CORTICAL BONE
Early vascularization Not Completely revascularised
for 2 months
Increased number of viable
cells
Relatively less
Apposition followed by
resorbtion
Resorbtion followed by
apposition
Completely replaced by new
bone
Remains as composite of new
&
necrotic bone
Greater mechanical strength
earlier
More susceptible to infection

Graft use for ABG
Site Advantages Disadvantages
Iliac
crest
•Large quantity of
cancellous bone.
•Decreased operative-
time with 2 team
approach.
•No growth
disturbance
•Easy to condense &
pack
•Proven successful
•Mild transient
gait
disturbance
•Donor site
morbidity
reported in
literature

Proximal
tibia
•Adequate cancellous
bone
•Minimal soft tissue
dissection
•Two team approach
• Mild post-op
discomfort
•Less bone than
iliac bone
•Interferes with
growth
•(due to
epiphyseal
growth
•plate)
Rib
Two team approach
possible
Mainly used in primary
ABG
•Poor source of
cancellous bone
•Post-op-pain
•Visible scar
•Associated
morbidity
•Un predictable
result

Cranial bone
•Incision hidden
in hair bearing
area
•Minimal postop
discomfort
•Sparse cancellous
bone
•Increased
operative time
•Associated
morbidity
•Poor results than
ilium
(less cellular)
•Stigma & fear for
patient
Mandible
symphysis
Same operative
field
Rapid post-op
recovery
No external scar
•Sparse amount of
•cancellous bone
•Associated
morbidity
•Poor result than

Type Advantages Disadvantages
Allogenic:
derived from a
genetically
unrelated
member of same
species
(osteoconductive
, osteoinductive
Comparable to
autogenous
Allows for
eruption of teeth
Avoids donor
site morbidity
No
osteogenic
potential
Delayed
incorporation
Alloplastic: inert
foreign body
material
(osteoconductive
, osteoinductive
Avoids donor
site morbidity
Delayed healing
Inability of teeth
to erupt

Surgical technique
 Three basic surgical principles must
be satisfied for the successful
treatment of the alveolar cleft grafting:
 (1) closure of oronasal fistula,
 (2) adequate volume of graft material,
 (3) water tight and tension-free
closure.

Unilateral alveolar cleft
Incision line for an
oblique sliding flap
(dashed line)

The closure of the nasal mucosa
and the introduction of the bone
graft to the alveolar defect.
Depiction of the nasal
mucosa flap along with the
closure of the oral mucosa.

Final mucosal
closure of the
oblique sliding flap.
A palatal splint placed
over the closure area
to prevent formation of
a hematoma and
stabilize the bone graft.

Bilateral alveolar cleft repair
A bilateral alveolar
cleft palate
Needle palpation of the
bony edges of the
alveolar cleft while
injecting local anesthesia

The incision line
(dashed line)
Elevation of the nasal mucosa
on the left and closure of the
nasal mucosa on the right.
Placement of the bone graft
over the closed

Palatal depiction of the movement of the adjacent
mucosa in the oblique sliding flap technique

Mucosal closure in a bilateral alveolar
cleft.

Final closure of the bilateral alveolar
cleft repair using a oblique sliding flap
technique

Post-operative instructions
 Liquid diet 7 days
 Avoidance of trauma to the site
 Antibiotics & nasal decongestants
 Meticulous oral hygiene with
chlorhexidine

Complications
 Failure of bone grafts (Mainly in
mobile
premaxilla)
 Infection
 Wound breakdown & loss of graft
(incomplete oral/nasal closure)
 External root resorbtion
 Bone loss
 Residual fistula

Success of
ABG
 Good nasal side closure
 Use of adequate amount of cancellous
bone
 A water tight oral side closure
 Adequate amount of attached mucosa
in the area of cleft for development of
normal periodontal attachment of
erupting canine

Gingivo-Periosteoplasty
 Boneless primary bone graft
 Relies on the osteoinductive capabilities of
the periosteum
 Skoog T: The use of periosteum and surgicel for bone
restoration in congenital clefts of the maxilla. Scan J Plast
Reconst Surg 1: 113, 1967
 Wood RJ, Grayson BH, Cutting CB: Gingivoperiosteoplasty
and midfacial growth. Cleft Palate Craniofac J 34:17-20,
1997
 Carstens MH: Functional matrix cleft repair: principles
and techniques. Clin Plast Surg 31:159-189, 2004

 Advantages
 Repairs the cleft in
anatomic way by a
precise reconstruction
of the functional
matrix(mucoperiosteal
matrix of maxilla)
 Avoids the need for
ABG

Distraction osteogenesis
 Advantage
 No need for bone graft
 No donor site morbidity
 Minimal surgical time
 Bone height & width similar to normal
adjacent alveolus
 Dental implants possible
 Final orthodontic tooth movement is
good
 Minimal morbidity

 Disadvantage
 Long treatment requires patient co-
operation & close follow-up

Conclusion
 Although the repair of the alveolar cleft
may be one of the last considerations
in the global treatment of a cleft
patient, if these goals are achieved, it
provides tremendous enhancement of
oral function and aesthetics for a cleft
patient.

References
 Peterson 2nd edition vol II
 OUTLINE OF ORAL &MAXILLOFACIAL
SURGERY- Peterwardbooth vol II
 Oral Maxillofacial Surg Clin N Am 14
(2002) 477–490
 Medical embryology by langman

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