Cleft alveolar bone grafting /certified fixed orthodontic courses by Indian dental academy

CLEFT ALVEOLAR BONE
GRAFTING

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Cleft Alveolar Grafting
Latin Terminology - A small trough that
contains the tooth buds
Anatomy - Anatomically a complete
Cleft of the alveolus passes
superiorly in to the Nasal Cavity &
Posteriorly in to the anterior
palate, with Continuation of the alveolar,
Nasal and Palatal Mucoperiostium

Common Sites

* Between Lateral Incisor & Canine
(No-4 Tessier Classification)
* Between Central and Lateral Incisor
(No -3 Tessier Classification)
* Rare - Between Central Incisors
(No-0 Tessier Classification)
* More Distally
(No -5 & 6 Tessier Classification)

History
* Drachter (1914) first attempt of Bone graft of alveolar
Cleft
*Veau (1931) classification and attempted tibial graft to
cleft palate
* Nordin et al. (1955) early repair cleft alveolus and
palate with autogenous bone
* Jolley et al. (1968) described the detrimental effects of
early bone graft on Maxillary growth.
* Boyne & Sands ( 1972) protocols for secondary bone
grafting
*Wolf et al.(1983) showed favorable results using
calvarian bone
* Nique et al.(1987) performed alveolar grafting with
allogenic bone

_______ Problems
Patients _________
•Food / Fluids coming out of their nose
•An Inability to blow balloons or to suck a straw
•A persistent smell from the Nose
•Poor speech
•An Inability to clean
•Deformed / missing teeth
•Mobility and overgrowth of the pre maxilla
•Lack of alar base & columella


Surgical goals of Alveolar
Bone Grafting and Reconstruction
* Stabilization of the Dental osteal segments & Mobile
Premaxilla in bilateral cases
* Oronasal fistula closure
* Improvement in the Alveolar ridge form so
that an Implant or Prosthesis can be placed.
* Prevention of tooth loss due to lack of
Periodontal bone support
* Provision of the Nasal alar support


Benefits
* Stabilization of the dental arch and closure of the Oronasal
fistula are the major benefits of alveolar grafting.
* The greater segment has tendency to collapse due
to lack of alveolar continuity and palatal scarring.
* Transverse deficiency with posterior lateral crossbite.
* Lack of vertical growth in the cuspid region resulting in a
vertical maxillary deficiency.
* Anterior maxillary crossbite.


Classification of Alveolar Grafting
* Primary Bone grafting : Less than 2 Years of age.
* Early secondary Bone grafting : 2-6 Years of age.
* Secondary Bone grafting : 7-12 Years of age.
* Late secondary Bone grafting : Adult.
* Grafting at the time of Le forte I Osteotomy.
* Revision grafting.


Timing of Bone Grafting Primary
☻Primary bone grafting before the age of two was routinely
done during the 1950-1960’s.
☻Jolley et al (1968) demonstrated significant limitation
of anterior- posterior growth in these patients with and
increased incidence of cross bites.


Timing of Bone Grafting
Early Secondary
* Early secondary bone grafting, between the age
of 2 & 6 is done primarily to provide Alveolar Bone
support for the eruption of the lateral incisor.
* Radiographic evaluation of the lateral incisor & canine
associated with the Cleft defects will help to determine
timing of the graft.
* The most common time for Alveolar Cleft Grafting is
between the age of 9 & 11 Years.


*Before the eruption of the canine when the root is
1/2 to 2/3 formed
* Grafting between the age of 9 and 11 does not have
much effect on midface growth and will provide boney
support for the erupting canine

Timing of Bone Grafting Adults
* Higher incidence of graft failure is noted.
* Closure of Oronasal communication and providing
a stable Maxillary arch are the primary objectives.


Surgical Preparation
Orthodontic management - Mixed Dentition Stage
- Cross bite correction
- Alignment of teeth
- Expansion appliance - 3 months
Surgical Preparation

- Soft Tissue Evaluation
- Flap Design
- Periodontal Support
- Oronasal Communication
- Support of the Alar Base
- Evaluate the Donor site.


Fundamental Principles
Nasal side closure first
Adequate volume of Bone
Water tight tension free closure of the mucosa


Postoperative Management
☻ Clear liquid diet for 3-5 days followed by a soft diet, oral hygiene
☻ Evaluate for dehiscence over Bone Graft
☻ Absolutely no trauma or loading to the area, including tongue.
☻ 8 weeks.

Complications
☻ Infection
☻ wound dehiscence
☻ loss of graft
☻ Incomplete closure

Success Rates
Cohen et al 1996 (Teaching model)
1. Fistula closure (95%)
2. Canine eruption, Bone support to adjacent teeth (95%)
3. Bone Architecture - Bone strut (95%)
Abyholum and Bergland - Radiological Grading
Grade I : Normal interdental Alveolar height
Grade II : > 75% Normal interdental Alveolar height
Grade III : 50 to 75% Normal interdental Alveolar height
Grade IV : < 50% Normal interdental Alveolar height
Success varies from 0 to 100 % and is usually at 60 to 80%

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