Alveolar cleft grafting

The alveolar cleft defect is usually not corrected in the original surgical correction of the cleft lip or the cleft palate. As a result the individual may have residual oro-nasal fistulae in this area, and the maxillary alveolus will not be continuous because of the cleft. Because of this, five problems commonly occur:

Alveolar cleft CT

1. Oral fluids escape into the nasal cavity;
2. Nasal secretions drain into the oral cavity;
3. Teeth erupt into the alveolar cleft;
4. The alveolar segments collapse; and
5. If the cleft is large, speech is adversely affected.

Panorex xray showing defect (red arrow) in the alveolus with maxillary canine tooth erupting into the cleft about age 13

Advantages

• They unite the alveolar segments and help prevent collapse and constriction of the dental arch, which is especially important if the maxilla has been orthodontically expanded.
• Alveolar cleft bone grafts provide bone support for teeth adjacent to the cleft and for those that will erupt into the area of the cleft. Frequently, the bone support on the distal aspect of the central incisor is thin, and the height of the bone support varies. These teeth may show slight mobility because of this lack of bone support. Increasing the amount of alveolar bone for this tooth helps ensure its periodontal maintenance, especially if bone grafting occurs before the early stages of eruption of the tooth. The canine tends to erupt into the cleft site and, with healthy bone placed into the cleft, will maintain good periodontal support during eruption and thereafter.
• Closure of the oro-nasal fistula, which will partition the oral and nasal cavities and prevent the escape of fluids between them.
• Augmentation of the alveolar ridge in the area of the cleft is the another advantage because it facilitates the use of dental prostheses by creating a more suitable supporting base.
• Creation of a solid foundation for the lip and alar base of the nose. It has become evident that the alveolar cleft-grafting procedure itself creates a favorable change in the nasal structure because the tissues at the base of the nose become supported after alveolar cleft grafting, whereas they had no solid osseous foundation before the graft. Therefore the alveolar graft should be performed before nasal revisions.

Timing of Graft Procedure

The alveolar cleft graft is usually performed when the patient is between ages 6 and 10 years. By this time, a major portion of maxillary growth has occurred, and the alveolar cleft surgery should not adversely affect the future growth of the maxilla. It is important to have the graft in place before the eruption of the permanent canines into the cleft, thus ensuring their periodontal support. Ideally, the grafting procedure is performed when one-half to two-thirds of the unerupted canine root has formed. Some surgeons advocate that alveolar grafting be performed nearer to the time when the maxillary central incisors are erupting.

Orthodontic expansion of the arch before or after the procedure is equally effective; however, some surgeons prefer to expand before bone grafting to facilitate access into the cleft area at surgery.

Surgical Procedure

Intact mucoperiosteal flaps on each side must cover bone grafts placed into the alveolar cleft. This means that flaps of nasal mucosa, palatal mucosa, and labial mucosa must be developed and sutured in a tension-free, watertight manner to prevent infection of the graft. The soft tissue incisions for alveolar cleft grafts vary, but in each procedure, these conditions are met.

The bone placed into the alveolar cleft is usually obtained from the patient’s ilium or cranium; however, some surgeons are using allogeneic bone (i.e., homologous bone from another individual) and recently bone morphogenetic proteins have been used for this purpose. The grafts are made into a particulate consistency and are packed into the defect once the nasal and palatal mucosa has been closed. The labial mucosa is then closed over the bone graft. In time, these grafts are replaced by new bone that is indistinguishable from the surrounding alveolar process. Orthodontic movement of teeth into the graft sites is possible, and eruption of teeth into them usually proceeds unimpeded. Implants may also be placed.

Surgical incisions of alveolar cleft palate repair

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