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Alveolar Bone GraftingAlveolar Bone Grafting

Jaime Gateno, DDS, MDAssociate ProfessorOral and Maxillofacial Surgery

Alveolar Bone GraftingAlveolar Bone Grafting

Rational Age Type of Bone and Donor Site Timing of Maxillary Expansion Techniques

Alveolar Bone GraftingRational

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 1950’s -60’s 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

osteoconductionNique 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 alloplastHorswell 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 GraftTechnique

Incision and flap design for unilateral cleft defect repair

Alveolar Bone GraftTechnique

Elevation of labial and buccal mucoperiosteal flaps

Alveolar Bone GraftTechnique

Creation of labial and palatal flaps after excision of intradefect fistula

Alveolar Bone GraftTechnique

Buccal flap elevated superiorly

Palatal flaps elevated and pushed posteriorly

Alveolar Bone GraftTechnique

Closure of nasal floor mucosa superiorly (NF) and palatal mucosa (PM) posteriorly

NFNF

PM

Placement of particulate cancellous bone into defect

Alveolar Bone Graft Technique

Alveolar Bone GraftTechnique

Alveolar Bone GraftTechnique

Labial pedicled “finger” flap elevated to cover bone graft as alternative to sliding buccal mucoperiosteal flap

Preoperative Cleft Defect Postoperative Bone Graft