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___________________________________________________________________________________ ISSN 0970 - 4388

Secondary Bone Grafting in Cleft lip and Palate with Eruption of Tooth into
the Graft: A Case Report.
BATRA P a , SHARMA J b , DUGGAL R c , HARI PARKASH d

ABSTRACT effects of primary surgery on the maxillary growth. Mostly


Secondary bone grafting in cleft lip and palate patients is performed the Oslo cleft team is based on sound biological and technical
preferably before the eruption of permanent canine in order to provide
principles and has extensively reported secondary bone
adequate periodontal support for eruption and preservation of the
teeth adjacent to the cleft. Presented here with is a case of unilateral grafting in literature. Grafted cancellous bone fills in the residual
cleft lip and palate, which was followed up from birth to 15 years of alveolar cleft and is anatomically joined to the adjacent bone,
age. The role of an orthodontist in the team approach for management becoming indistinguishable in radiographic images after an
of such anomalies is described. Also discussed in detail is the entire
average period of 3 months. From an orthodontic viewpoint,
range of treatment procedures the child underwent, especially the
role of secondary bone grafting. the most important benefit of secondary bone grafting is that
the newly grafted bone acts as the alveolar bone, allowing
Keywords : Bone grafting, Cleft lip, Cleft palate, Secondary' the spontaneous migration of the adjacent canine towards
the alveolar ridge. Therefore, bone grafting has become
INTRODUCTION
mandatory in the treatment protocols of cleft patients,
The main difference in the interdisciplinary treatment protocol establishing two well-defined stages for orthodontic
in the management of cleft lip and palate is the timing of mechanotherapy (pre and post secondary bone grafting).
occurrence of bone grafting. Accordingly the graft may be During the prebone grafting orthodontic phase, the upper dental
classified as primary, secondary and tertiary. When performed arch is prepared for the graft and the permanent incisors are
during early childhood, at the same time as the primary repair aligned whenever necessary. The pregraft orthodontic
surgeries, bone graft is called as primary. Some authors believe treatment also results in better access for the surgeon at the
that this early procedure can cause impairment of the maxillary time of the grafting procedure. The presurgical orthodontic
growth. Because of its controversial and counterproductive preparation involves predominantly transverse mechanics with
aspect, most rehabilitation centers that used to perform it the use of orthodontic or preferable orthopedic expansion
have abandoned this technique. Bone grafting is called as during the mixed dentition in order to reposition the palatal
secondary when performed later at the end of the mixed segments. Occasionally some patients are subjected to
dentition. It is the most accepted procedure and is performed maxillary protraction in addition to expansion in order to correct
preferably before eruption of the permanent canine in order to maxillary antero-posterior deficiencies. Three months after
provide adequate periodontal support for eruption and the bone graft procedure, and depending on the radiographic
preservation of the teeth adjacent to the cleft. When bone image of the area, orthodontic treatment is restarted to correct
grafting is performed in the permanent dentition after the the position of the permanent teeth. This phase involves
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completion of orthodontic treatment, it is called a tertiary or movement of the teeth through the grafted area .
late graft. Tertiary grafts are performed to enable prosthodontic Here a case of unilateral cleft lip and palate is described,
and periodontal rehabilitation and to assist in the closure of which was followed up in our hospital from birth to 15 years of
persistent bucconasal fistulae. A tertiary or late bone grafting age. The role of an orthodontist in the team approach for
cannot repair bone loss in teeth adjacent to the cleft. management of such anomalies is also discussed.
Occasionally, tertiary grafts cause progressive root resorption
CASE REPORT
on the cervical thirds of roots of teeth adjacent to the cleft,
especially canines. Such root resorption is caused by the A 2-day-old child born in a district hospital was referred to
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contact of the grafted bone to the exposed root surface . the dental surgery department of AllMS for management of
Studies show that secondary bone grafting can repair the facial deformity. The child had been born with unilateral cleft
cleft alveolus without increasing the already known iatrogenic lip and palate (primary palate). The patient's parents were
counseled, as they were very apprehensive and disturbed.
a. Senior Resident, b. P. G. Student, c. Associate Professor,
Secondary bone grafting in cleft lip and palate

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regular follow-up. Feeding instructions were given. Surgical goals of alveolar bone grafting and reconstruction
The lip repair was done when the child was three months old • Stabilization of the dental osteal segments
and the palate repair was carried out when he was eighteen • Oronasal fistula closure
months old (Fig 1). The patient was referred to a speech • Improvement in the alveolar ridge form
therapist for speech correction. Meanwhile the patient was • Prevention of tooth loss due to lack of periodontal bone
under regular recall in the dental OPD where instructions support
were given regarding maintenance of good oral hygiene. When • Provision of the nasal alar base support
the patient was in mixed dentition he was referred to the • Stabilization of the dental arch and closure of the oronasal
orthodontic clinic for further management. The initial treat- fistula
ment comprised of only crossbite correction of the upper left • The greater segment has a tendency to collapse due to
central incisor by removable appliance only. When the pa- lack of alveolar continuity and palatal scarring
tient was in late mixed dentition the radiographic records like • Transverse deficiency with posterior lateral crossbite
the lateral cephalogram, OPG and occlusal x-rays of the max- • Lack of vertical growth in the cuspid region resulting in a
illa were evaluated. It was found that the upper left lateral vertical maxillary deficiency
incisor adjacent to the cleft site had no bone support. Also a • Anterior maxillary crossbite
posterior crossbite had developed. However the extraoral pho- Early secondary bone grafting, between the ages of 2 and 6
tographs showed an acceptable result of the lip repair (Figs 2 is done primarily to provide alveolar bone support for the
and 3). Expansion was done in the posterior segment using eruption of the lateral incisor. The lateral incisor is often
a NiTi palatal expander. Post expansion the patient under- malformed, congenitally missing, or erupts ectopically.
went a secondary bone grafting in the cleft region. The bone Radiographic evaluation of the lateral incisor and canine
was harvested from the iliac crest (Fig 4). Simultaneously lip associated with the cleft defect will help to determine timing
revision with columelloplasty was done to correct the nasal of the graft. 95% of the anteroposterior and transverse growth
deformity (Figs 5 and 6). After 3 months full comprehensive is completed by the age of 8 and therefore the most common
orthodontic treatment was initiated. After the leveling and align- time for alveolar cleft grafting is between the ages of 9 and 11
ment the patient was referred to the prosthodontic division for (before the eruption of the canine when the root is 1/2 to 2/3
fabricating the crowns in the left central and lateral incisors formed). Anteroposterior and transverse growth is completed
as they were hypoplastic and the lateral was peg shaped as by this age and only vertical growth remains. Grafting between
well as the canine. Debonding was done after attaining a the ages of 9 and 11 does not have much effect on midface
good occlusion (Fig 7). The facial photographs after the bone growth and will provide bony support for the erupting
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grafting and lip revision showed a commendable change in canine . The anterior iliac crest is the most common donor
the nasal and lip deformity. The lateral incisor erupted through site used today (gold standard). This site is preferred as the
the newly grafted bone. The OPG of the patient 6 months amount of bone, which can be mobilized in adequate amount
after the grafting procedure showed an adequate bone in the and has high particulate cancellous bone content. Calvarium
cleft site (Fig 8). Thus with a team approach an acceptable and mandibular bone has been advocated, as being a superior
face and occlusion was given to this child. donor however there is inconsistent clinical results. However
the bone is membranous, less particulate cancellous bone
DISCUSSION and quantity harvested is inadequate.
Radiographic follow-up demonstrated adaptation of the
All the patients at the combined cleft lip and palate clinic at cancellous bone of the iliac crest to the host area, making it
AIIMS undergo the following treatment protocol: impossible to distinguish the mesial and distal limits of the
• Primary surgery performed during childhood (lip repair cleft. In addition, it was radiographically apparent that canines
after 3 months of age and palate repair after 12 months migrate towards the occlusal plane through the grafted bone
of age) and create good periodontal conditions. The findings of present
• No early pre and post surgical maxillary orthopedics case agree with other studies in which teeth erupted through
• Orthodontic treatment during the mixed dentition the grafted bone. Cancellous bone graft is quickly incorporated
• Secondary bone grafting at the end of mixed dentition and vascularized and most importantly, does not interfere in
Secondary bone grafting in cleft lip and palate

Fig. 1: Patient before lip repair and 2 months after Fig. 2: Pretreatment extraoral views at 10 years of age.
repair.

Fig. 3: Pretreatment intraoral photographs.

Fig. 4: Harvesting bone from iliac crest and grafting into the cleft site.
Secondary bone grafting in cleft lip and palate

Fig. 5: Extraoral photographs after secondary bone Fig. 6: Post bone grafting extraoral photographs.
grafting and lip repair.

Fig. 7 : Post treatment intraoral photographs.

Fig. 8: Pretreatment OPG and OPG after 6 months of bone grafting.


Secondary bone grafting in cleft lip and palate

presence of the tooth contributes to the preservation of the Periodontal evaluation of canines erupted through grafted
grafted bone and to the differentiation of the periodontal alveolar cleft defects. J Oral Maxillofac Surg 1984;42:717-
17,18 721.
support .
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