Alveolar Bone Grafting

Jaime Gateno, DDS, MD

Associate Professor
Oral and Maxillofacial Surgery

Alveolar Bone Grafting

Rational
Age
Type

of Bone and Donor Site

Timing of Maxillary Expansion
Techniques

Alveolar Bone Grafting

Rational
Provide

bone for the eruption and/or

orthodontic repositioning of teeth
Closure of oro-nasal fistulas
Support and elevation of the alar base
Stabilization of the pre-maxilla in bilateral
cases
Provide continuity of the alveolar ridge

Definitions
Primary

Bone Grafting

Bone graft done at the time of primary cheiloplasty

Bone graft done during the first 2 years of life
Bone graft done prior to the eruption of the primary
canine

Definitions
Secondary

Bone Grafting

Early
Intermediate (Secondary)
Late

Secondary Bone Grafting

Done

before eruption of the permanent canine

Usually when the root of the canine is 1/3 to
2/3 formed
Usually between ages 8-10
In CLP dental age is usually behind
chronological age

Early Secondary Bone Grafting

Done

before eruption of the permanent lateral

incisor
Usually when the lateral is 1/3 to 2/3 formed
Ages 5-6
Lateral incisor is frequently hypoplastic

Late Secondary Bone Grafting

Done

after eruption of the permanent canine

Usually during adolescence or adulthood
Sometimes done concomitantly with
orthognathic surgery

Primary Bone Grafting

Popular

in the 1950s -60s

Usually done in conjunction with maxillary
orthopedics
Rib grafts placed either simultaneously with lip
repair or shortly after
Largely abandoned due to questions about
maxillary growth and development
Still done in some centers

Primary Bone Grafting

Rational

Prevention of maxillary arch collapse

Migration of teeth into the alveolar process
Stabilization of the pre-maxilla in bilateral cases
Support for the alar base

Dado DV. Early Primary Bone Grafting. In: Kernahan DA, Rosenstein
SW, eds. Cleft Lip and Palate. A System of Management. Williams
and Wilkins, Baltimore, 1990. pp 182-188.
Nelson CL: Primary Alveolar Cleft Bone Grafting. Oral Maxillofac
Surg Clin NA 3:599, 1991.

Primary Bone Grafting

Disadvantages

Data suggest that primary bone grafting has a negative effect on

maxillary growth and nasolabial appearance
May necessitate further bone grafting in childhood due to
insufficient alveolar bulk

Friede H, Johanson B: Adolescent facial morphology of early bone

grafted cleft lip and palate patients. Scand J Plast Reconstr
Surg 16:41-53, 1982
Trotman CA, etal: Comparison of facial form in primary alveolar
bone-grafted and nongrafted unilateral cleft lip and palate
patients. Cleft Palate Craniofac J 33:91, 1996

Primary Bone Grafting

Primary Bone Grafting

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

Secondary Bone Graft

Performed most commonly

Particulate autogenous cancellous bone
most common graft
No observed growth disturbance

Type of Bone
Autogenous

Cancellous- iliac crest

Block
Particulate

Cortical- calvarium, mandible

Bone

dust
Blocks

Cortico-cancellous- iliac, rib, tibia, mandible (tibia

and mandible only in late secondary grafting)

Type of Bone

Allogeneic
Graft resorbs, remodels, may contribute to osteoinduction and
osteoconduction
Nique T, Fonseca RJ, et al: Particulate allogeneic bone grafts into maxillary
alveolar clefts in humans- A preliminary report. J Oral Maxillofac Surg
45: 386-392, 1987

Alloplast
Bone grows into, around alloplast
No active osteoinduction but some osteoconduction
Teeth do not erupt through alloplast
Horswell BB, El Deeb M: Nonporous HA in the repair of alveolar cleft defect
in a primate model. J Oral Maxiilofac Surg 47:946-952, 1989

Timing of Maxillary Expansion

Before

Primarily for later secondary grafting

Optimal positioning of cleft segments and
reorientation of teeth collapsed into defect

After

Alveolar Bone Grafting

Alveolar Bone Grafting

Earlier secondary grafting

Alveolar Bone Graft

Technique

Incision and flap design for

unilateral cleft defect repair

Alveolar Bone Graft

Technique

Elevation of labial and

buccal mucoperiosteal
flaps

Alveolar Bone Graft

Technique

Creation of labial and palatal

flaps after excision of
intradefect fistula

Alveolar Bone Graft

Technique

Buccal flap elevated

superiorly
Palatal flaps elevated and
pushed posteriorly

Alveolar Bone Graft

Technique

NF

PM

Closure of nasal floor

mucosa superiorly (NF)
and palatal mucosa (PM)
posteriorly

Alveolar Bone Graft

Technique

Placement of particulate
cancellous bone into defect

Alveolar Bone Graft

Technique

Alveolar Bone Graft

Technique

Labial pedicled finger flap

elevated to cover bone graft as
alternative to sliding buccal
mucoperiosteal flap

Preoperative Cleft Defect

Postoperative Bone Graft