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J Oral Maxillofac Surg

40:721-725 1982

Retrospective Study of lveolar

Cleft Grafting

JAMES B. TROXELL, DDS, MS,* RAYMOND J. FONSECA, DMD,t AND

DONALD B. OSBON, DDS

A surgical technique for the bone graft repair of alveolar clefts is described,

and an evaluation of the conditions of 30 patients who have undergone

that procedure is reported. Evaluation was made specifically for the pre-

operative and postoperative presence of oronasal fistula, postoperative

eruption of previously unerupted teeth into the graft, soft and hard tissue

periodontal status, and radiographic evidence of bone fill in the previous

cleft defect resulting in alveolar segmental stabilization.

Early alveolar bone grafting as part of the repair

of cleft palates was enthusiastically endorsed by

many workers in the late 1950s and early 196Os.-

The advantages cited were these: (1) control or fix-

ation of the maxillary arch with prevention of col-

lapse, (2) unit growth of the maxilla with eruption

and movement of teeth through the grafted bone,

and (3) proportional growth of the maxilla with the

mandible to maintain proper dental occlusion. Re-

pairs were performed in children from infancy to

age 2.

Early clinical follow-up studies began to show

less than satisfactory results, disagreements arose

about the reasons why the procedure did not fulfill

early expectations. Bone grafts of the alveolus were

frequently suggested to be the damaging element in

the overall cleft palate repair regimen. However, no

universal recording system was used, and the early

results from the different surgical centers often

presented conflicting findings. At the 1963 conven-

tion of the American Cleft Palate Association, Pru-

zansky referred to primary bone grafting as a

surgery that is needless and sometimes barbaric.

He pleaded for a concern for biological mecha-

nisms. Shortly thereafter, other reports appeared

that described unsatisfactory results, the greatest

objection being to the effects on maxillary growth.

4: ormerly Senior Resident in Oral and Maxillofacial Surgery:

now in private practice in Fort Collins, Colorado.

t Associate Professor and Director of the Residency Program

in Oral and Maxillofacial Surgery.

$ Full Professor and Chairman of the Department of Oral and

Maxillofacial Surgery.

Received from the University of Iowa Hospitals and Clinics.

Iowa City, Iowa 52242.

Address correspondence and reprint requests to Dr. Fonseca.

For proper growth and development to occur,

cleft repair of any sort ideally should be delayed

until after growth is complete. However, nutrition,

speech, swallowing, esthetics, and psychologic well-

being make the problem complex. Early soft tis-

sue repair of the cleft lip and palate is necessary

for the attainment of normal speech, swallowing,

and psychologic acceptance. Clifford reported the

greatest dissatisfaction: that on long-term follow-up,

patients with cleft palate were displeased with the

appearance of their teeth and with their speech. The

goal of all cleft palate repair procedures is to

achieve the best possible physiologic and psycho-

logic function with a minimum of disturbance to

growth and development.

In the 197Os, studies appeared suggesting that, if

bone graft repair of alveolar clefts was delayed until

the age of mixed dentition (about 8 to 14 years),

good function would result, and there would be

much less effect on growth and development.

Boyne and Sands reported the results of alveolar

cleft grafting on ten patients. Their recommended

operation time was between ages 9 and 11, before

the canine teeth had fully erupted. The procedure

involved grafting autogenous cancellous bone and

marrow to clefts in patients not requiring ortho-

gnathic surgery but in need of teeth in the newly

restored osseous alveolar ridge. The oronasal soft

tissue communication was closed during the proce-

dure. Canine teeth erupted into the grafted areas in

eight patients. A reported minor complication was

vestibular sulcus shortening, which could be cor-

rected later by vestibuloplasty.

Broude and Waite reported 33 cases in which

iliac crest bone was used to close alveolar defects.

A majority of their patients with cleft palate showed

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722

severe malocclusions, which required maxillary seg-

mental or total maxillary orthognathic surgery prior

to repair of the alveolar defect. In these cases the

alveolar graft was performed two to three months

later. These workers emphasized the importance

of a careful closure of the nasal mucosa for a suc-

cessful graft. A labial pedicle flap from the vestibule

was used to cover the bone graft.

Waite and Kerste@ stated that if the alveolar

ridge defect were left untreated, one or more of the

following features would be present:

1. Alveolar ridge displaced palatally on the cleft

side with frequent tooth malalignment.

2. Deficient bone support for teeth adjacent to

cleft.

3. Inadequate oral hygiene due to oronasal fistula

and malaligned teeth.

4. Maxillary segmental mobility and compro-

mised prosthetic appliances.

5. Affected speech from altered arch contour

and/or fistulae.

Epker and Wolfords found that when properly

timed and performed, alveolar grafting provides

relatively normal alveolar bone continuity, good

stabilization for mobilized or expanded maxillary

dento-osseous segments, and supporting bone for

adjacent teeth to erupt into or be orthodontically

moved into and can improve the periodontal health

and longevity of teeth adjacent to the cleft. They

list the basic goals for surgery as follows:

1, Stabilization of dento-osseous segments.

2. Improvement of alveolar continuity.

3. Prevention of tooth loss due to periodontal dis-

ease.

4. Provision of alar base support.

The preferred time for alveolar cleft grafting ac-

cording to Waite and Kerster? is between the ages

of 9 and 11, before the canine teeth have fully

erupted. Ideally, the canine tooth should be high in

the alveolus on the cleft side. Their surgical tech-

nique involved closing the mucosa of the nasal

floor, placing a cortical-particulate medullary iliac

crest graft, and closing with a pedicled mucosal or

mucoperiosteal flap. They observed that the pedi-

cled flap rarely foreshortened the vestibule.

The purpose of this study is to describe a tech-

nique for alveolar cleft grafting and to evaluate the

results obtained with this procedure.

Materials and Methods

The 30 patients selected for this study had under-

gone a grafting procedure of either unilateral or

bilateral alveolar cleft at the University of Iowa

Hospitals and Clinics from 1977 to 1980. Those pa-

tients no longer being followed up routinely were

telephoned and an interview and examination were

LVEOL R CLEFT GR FTING

arranged. Routine follow-up appointments were used

for subjects more recently operated on. Several of

the appointments were made in conjunction with

orthodontic follow-up.

At the time of the recall examination, the length

of time since the graft, age at the time of surgery,

and present age of the patient were noted. An

occlusal radiograph was taken, and if malaligned

teeth obscured the graft site, periapical radiographs

were also taken. All subjects were examined and

radiographs interpreted by the same person (JBT).

Sixteen female and 14 male subjects were exam-

ined at an average of 17.1 months after surgery

(range 2 to 26 months). The success of the grafts

was evaluated in terms of the following features:

presence of oronasal fistulae, eruption of previously

unerupted teeth into graft, soft and hard tissue peri-

odontal status, and radiographic evidence of bone

fill in the previous cleft defect resulting in alveolar

segmental stabilization. The average age at the time

of surgery was 13.2 years, with a range of 7 to 26

years.

PREOPERATIVE NFORMATION

The chief complaint or reason for surgery was

recorded for each patient. The information came

from either the patient, the parent (s), or the admis-

sion history and physical examination. The nature

of the alveolar cleft (unilateral or bilateral) as well

as any associated syndrome was recorded. The

source of the bone graft material was discovered

from the admission history and physical examina-

tion. Information regarding the presence or absence

of an oronasal tistula was obtained from preopera-

tive photographs and the history and physical ex-

amination. Preoperative radiographs were used to

determine whether unerupted teeth were present

prior to the graft. Preoperative photographs and the

history and physical examination established whether

the patient was under orthodontic treatment before

surgery.

INTR ~~PERATI~E NFORMATION

The type of procedure performed and, in the case

of bilateral clefts, whether both clefts were treated

was recorded. Other factors tecorded were splint

placement, estimated blood loss, medications, and

immediate complications. Blood loss estimations

were made for both the cleft and iliac crest proce-

dures.

POSTOPERATIVE NFORMATION

The postoperative evaluation involved checking

for the presence of an oronasal fistula, a periodontal

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TROXELL ET AL

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examination of the maxillary teeth, and a radio-

graphic survey of bone bridging and tooth movement

into the graft site. A periodontal probe was used to

determine sulcular depth at six points around each

of the maxillary teeth. The zone of attached gingiva

was measured at the cleft site in the region of the

four-cornered suture placement. The presence or

absence of an oronasal fistula was noted clinically

and recorded with photographs. Tooth movement

was examined clinically and radiographically by

comparisons between preoperative and postopera-

tive films. Evidence of bone bridging was also eval-

uated radiographically.

TECHNIQUE FOR REPAIRING UNILATERAL CLEFTS

After general anesthesia was given in the operating

room, the patient was prepared and draped for si-

multaneous procurement of the iliac crest graft and

the alveolar cleft procedure. Either an oral or a

nasal endotracheal tube was used. An oral anode

tube was used most frequently because it allowed

complete access to the maxilla, nasal floor, and

upper lip and would not kink when head positions

were changed. Also, an oral tube would not disturb

a pharyngeal flap.

The iliac crest procedure was performed as de-

scribed in the literature.lO~li No cortical bone was

taken: the graft consisted of cancellous bone and

marrow. Approximately 20 cc was obtained, the

amount varying with the cleft size. With patients

treated before October 1979, the graft was stored in

the patients own blood until placement. After that

time, it was kept in normal saline, as recommended

by Marx. I2

After placement of a throat pack, the unilateral

cleft (Fig. 1, rtbove) was examined. Two percent

lidocaine with 1: 100,000 epinephrine was infiltrated

along the cleft for hemostasis and ease in dissection.

The anesthetic needle was used to probe the bony

margins of the cleft both palatally and labially. After

the width of the bony defect had been determined, a

pericoronal incision was made in the sulcus from

either the first or the second molar to the corre-

sponding tooth on the opposite side of the arch. An

incision was then made along the palatal aspect of

the cleft through mucosa to bone. The incision was

beveled to preserve palatal mucosa and to avoid the

need for inversion of a large amount of tissue into

the floor of the nose. The interdental papillae of the

teeth adjacent to the cleft were reflected to improve

visualization. An incision over the crest of the ridge

was made anterior and posterior to the cleft. Careful

reflection and handling of this tissue was important

because it was used in the four-cornered closure.

Often the anterior and posterior extent of the bony

cleft was not clearly demarcated. and the superior

FIGURE 1

Above,

Preoperative appearance of unilateral al-

veolar cleft.

Center,

Flap design for double layered closure of

defect and buccal and palatal advancement prior to grafting.

Brlau~, Buccal and palatal advancement flaps sutured in place

with four-corner approximation.

extent of the incision was therefore tapered into the

submucosal tissue. After adequate reflection of soft

tissue, the margins of the nasal mucosa were approxi-

mated with 4-O Vicryl suture on a P-2 cutting

needle. A careful check of the closure in the region

of the oronasal fistula was done because an epi-

thelium-lined tract would have jeopardized the

_

* Ethicon: polyglactin 910 braided suture.

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724

ALVEOLARCLEFTGRAFTING

FIGURE 2

Above Preoperative appearance of bilateral al-

veolar cleft defect with outline of palatal

and labiobuccal inci-

sions for the advancement flaps.

Center

Flap design for

double-layered closure of defect and buccal and palatal ad-

vancement flaps prior to grafting. Below, Placement of bone

chips and four-cornered closure of flaps.

closure. The nasal soft tissues were repositioned

superiorly to form the floor of the nose (Fig. 1,

center .

Vertical releasing incisions were made on the

palatal and labial aspects in the molar regions. Full

mucoperiosteal flaps were then reflected on the

palatal and labial aspects of the alveolus. Relaxation

of the labial flaps was gained by periosteal releas-

ing incisions. Generally, a tension-free closure was

obtained by advancement of the papillae one tooth

toward the midline. The palatal closure was begun

with 4-O Supramidt suture. The bone graft was

packed into the prepared site. Closure was com-

pleted with a four-comer suture over the graft site

and multiple simple interrupted sutures to approxi-

mate the remainder of the incision (Fig. 1, below). A

prefabricated acrylic splint was ligated to a tooth on

each side of the arch with 0.018 inch wire. Patients

were routinely given preoperative and postopera-

tive antibiotics and steroids. Decongestants were

given postoperatively as needed. A humidifier at the

bedside helped keep the patients nasal mucosa

moist. The splint and sutures were removed after 14

days.

TECHNIQUE FOR REPAIRING BILATERAL CLEFTS

The bilateral alveolar cleft graft procedure was

similar to the unilateral repair. Both clefts were

grafted in one stage. The incisions and flaps were

developed in the same fashion except in the pre-

maxillary region, where a mucoperiosteal tissue

cuff sufficient for closure was reflected from the

posterior aspect of the premaxilla (Fig. 2, above).

The nasal floor tissue was reflected and closed

bilaterally (Fig. 2,

center .

Periosteal and vertical

releasing incisions were important in the bilateral

procedures because the premaxillary tissue cuff did

not advance easily. After the graft was placed, the

oral closure was begun (Fig. 2, below). Two four-

comer sutures were tied, and the remainder of the

wound was closed with simple interrupted sutures.

Results

PREOPERATIVE PERIOD

The presence of an oronasal fistula was the most

frequent complaint prior to surgery. Most patients

had been referred by their orthodontists; three were

referred by prosthodontists.

Nine patients (30%) had unilateral right-sided

alveolar clefts, and 17 (57%) had left-sided defects.

Four clefts (13%) were bilateral, and 28 patients

(93%) had preoperative oronasal fistulae. In 19 pa-

tients (63%) an unerupted tooth adjacent to the cleft

site was visible in the radiograph. Twenty-two

(73%) of the 30 patients were receiving orthodontic

care at the time of surgery.

i S. Jackson. Inc.: polyamide polytilament suture.

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TROXELL ET AL

INTRAOPERATIVE PERIOD

The average estimated blood loss was 355 ml

(range, 75-1200 ml). The blood loss estimate was

for both the iliac crest procedure and the alveolar

cleft grafting. In addition, one patient underwent

bilateral intraoral vertical ramus osteotomies of the

mandible. The average length of hospitalization was

4.6 days, which included one-half day for admis-

sion, one-half day for discharge, one day for sur

gery, and 2.6 days for recovery time. All patients

received prophylactic antibiotics. Penicillin was the

drug of choice except for patients with a history of

allergy to penicillin. Dexamethasone was the anti-

inflammatory agent administered. Decongestants

were ordered as needed. No immediate postopera-

tive complications were observed.

POSTOPERATIVE PERIOD

The average size of the zone of attached gingival

tissue in the region of the four-cornered closure was

4.3 mm (range, O-10 mm). Postoperative tistulae

developed in two patients, one with a unilateral cleft

and the other with a bilateral cleft. Two patients had

dehiscence of the wounds; one admitted to nose-

blowing postoperatively, and the other was a juve-

nile diabetic with a bilateral cleft. In 18 of 19 pa-

tients (95%) with an unerupted tooth adjacent to

the cleft, there was tooth movement into the graft

site. In one case it was too early to determine

whether tooth movement would occur. No peri-

odontal sulcular depths greater than 4 mm were

measured: the average was 3 mm. Twenty-nine of

the 30 patients (97%) showed radiographic evidence

of bone bridging across the graft site.

iscussion

The need for greater stability of the alveolar seg-

ments is a recognized indication for bone grafting.

Twenty-nine patients showed bone bridging and in-

creased alveolar stability after surgery. In 28 pa-

tients, closure of an oronasal fistula was achieved.

As Broude and Waite7 and Epstein et all3 have em-

phasized, development and careful closure of the

flaps that become the nasal floor is essential for

success.

Grafting also favors tooth eruption. Seventeen of

18 patients with impacted canine teeth showed

725

either clinical or radiographic evidence of tooth mi-

gration into the bone graft. This compares favorably

with the results obtained by Waite and Kersten,

who reported that 75% of unerupted canine teeth

showed eruption into the bone graft.

Although various pedicle flap closures have been

described in the literature, these authors have not

seen the technique of bilateral buccal flap advance-

ments described previously. An advantage of the

technique is that a zone of attached gingival tissue is

placed over the cleft site to achieve a more natural

alveolar ridge. The average of more than 4 mm of

attached tissue provides acceptable periodontal

health for the adjacent teeth. The one patient in

whom tissue attachment did not occur later under-

went a successful free gingival graft with the use of

paptal mucosa. As noted by Waite and Kerstenx

the sulcular depth was decreased in some cases.

This can be corrected by secondary vestibuloplasty.

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