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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

 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
 Provide continuity of the alveolar ridge

 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

 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

 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 1950’s -60’s

 Usually done in conjunction with maxillary
 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-
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

 Boneless primary bone graft

 Relies on the osteoinductive capabilities of the

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
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 Alveolar Bone Grafting

– Primarily for later secondary grafting
– Optimal positioning of cleft segments and
reorientation of teeth collapsed into defect
 After Alveolar Bone Grafting
– Earlier secondary grafting
Alveolar Bone Graft

Incision and flap design for

unilateral cleft defect repair
Alveolar Bone Graft

Elevation of labial and

buccal mucoperiosteal
Alveolar Bone Graft

Creation of labial and palatal

flaps after excision of
intradefect fistula
Alveolar Bone Graft

Buccal flap elevated

Palatal flaps elevated and
pushed posteriorly
Alveolar Bone Graft

Closure of nasal floor

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

Alveolar Bone Graft

Placement of particulate
cancellous bone into defect
Alveolar Bone Graft
Alveolar Bone Graft

Labial pedicled “finger” flap

elevated to cover bone graft as
alternative to sliding buccal
mucoperiosteal flap
Preoperative Cleft Defect Postoperative Bone Graft