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  1. 1. Alveolar Bone Grafting Jaime Gateno, DDS, MD Associate Professor Oral and Maxillofacial Surgery
  2. 2. Alveolar Bone Grafting <ul><li>Rational </li></ul><ul><li>Age </li></ul><ul><li>Type of Bone and Donor Site </li></ul><ul><li>Timing of Maxillary Expansion </li></ul><ul><li>Techniques </li></ul>
  3. 3. Alveolar Bone Grafting Rational <ul><li>Provide bone for the eruption and/or orthodontic repositioning of teeth </li></ul><ul><li>Closure of oro-nasal fistulas </li></ul><ul><li>Support and elevation of the alar base </li></ul><ul><li>Stabilization of the pre-maxilla in bilateral cases </li></ul><ul><li>Provide continuity of the alveolar ridge </li></ul>
  4. 4. Definitions <ul><li>Primary Bone Grafting </li></ul><ul><ul><li>Bone graft done at the time of primary cheiloplasty </li></ul></ul><ul><ul><li>Bone graft done during the first 2 years of life </li></ul></ul><ul><ul><li>Bone graft done prior to the eruption of the primary canine </li></ul></ul>
  5. 5. Definitions <ul><li>Secondary Bone Grafting </li></ul><ul><ul><li>Early </li></ul></ul><ul><ul><li>Intermediate (Secondary) </li></ul></ul><ul><ul><li>Late </li></ul></ul>
  6. 6. Secondary Bone Grafting <ul><li>Done before eruption of the permanent canine </li></ul><ul><li>Usually when the root of the canine is 1/3 to 2/3 formed </li></ul><ul><li>Usually between ages 8-10 </li></ul><ul><li>In CLP dental age is usually behind chronological age </li></ul>
  7. 7. Early Secondary Bone Grafting <ul><li>Done before eruption of the permanent lateral incisor </li></ul><ul><li>Usually when the lateral is 1/3 to 2/3 formed </li></ul><ul><li>Ages 5-6 </li></ul><ul><li>Lateral incisor is frequently hypoplastic </li></ul>
  8. 8. Late Secondary Bone Grafting <ul><li>Done after eruption of the permanent canine </li></ul><ul><li>Usually during adolescence or adulthood </li></ul><ul><li>Sometimes done concomitantly with orthognathic surgery </li></ul>
  9. 9. Primary Bone Grafting <ul><li>Popular in the 1950’s -60’s </li></ul><ul><li>Usually done in conjunction with maxillary orthopedics </li></ul><ul><li>Rib grafts placed either simultaneously with lip repair or shortly after </li></ul><ul><li>Largely abandoned due to questions about maxillary growth and development </li></ul><ul><li>Still done in some centers </li></ul>
  10. 10. Primary Bone Grafting <ul><li>Rational </li></ul><ul><ul><li>Prevention of maxillary arch collapse </li></ul></ul><ul><ul><li>Migration of teeth into the alveolar process </li></ul></ul><ul><ul><li>Stabilization of the pre-maxilla in bilateral cases </li></ul></ul><ul><ul><li>Support for the alar base </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Nelson CL: Primary Alveolar Cleft Bone Grafting. Oral Maxillofac Surg Clin NA 3:599, 1991. </li></ul></ul>
  11. 11. Primary Bone Grafting <ul><li>Disadvantages </li></ul><ul><ul><li>Data suggest that primary bone grafting has a negative effect on maxillary growth and nasolabial appearance </li></ul></ul><ul><ul><li>May necessitate further bone grafting in childhood due to insufficient alveolar bulk </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  12. 12. Primary Bone Grafting
  13. 13. Primary Bone Grafting
  14. 14. Gingivo-Periosteoplasty <ul><li>Boneless primary bone graft </li></ul><ul><li>Relies on the osteoinductive capabilities of the periosteum </li></ul>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
  15. 15. Secondary Bone Graft <ul><li>Performed most commonly </li></ul><ul><li>Particulate autogenous cancellous bone </li></ul><ul><ul><li>most common graft </li></ul></ul><ul><li>No observed growth disturbance </li></ul>
  16. 16. Type of Bone <ul><li>Autogenous </li></ul><ul><ul><li>Cancellous- iliac crest </li></ul></ul><ul><ul><ul><li>Block </li></ul></ul></ul><ul><ul><ul><li>Particulate </li></ul></ul></ul><ul><ul><li>Cortical- calvarium, mandible </li></ul></ul><ul><ul><ul><li>Bone dust </li></ul></ul></ul><ul><ul><ul><li>Blocks </li></ul></ul></ul><ul><ul><li>Cortico-cancellous- iliac, rib, tibia, mandible (tibia and mandible only in late secondary grafting) </li></ul></ul>
  17. 17. Type of Bone <ul><li>Allogeneic </li></ul><ul><ul><li>Graft resorbs, remodels, may contribute to osteoinduction and osteoconduction </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><li>Alloplast </li></ul><ul><ul><li>Bone grows into, around alloplast </li></ul></ul><ul><ul><li>No active osteoinduction but some osteoconduction </li></ul></ul><ul><ul><li>Teeth do not erupt through alloplast </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  18. 18. Timing of Maxillary Expansion <ul><li>Before Alveolar Bone Grafting </li></ul><ul><ul><li>Primarily for later secondary grafting </li></ul></ul><ul><ul><li>Optimal positioning of cleft segments and reorientation of teeth collapsed into defect </li></ul></ul><ul><li>After Alveolar Bone Grafting </li></ul><ul><ul><li>Earlier secondary grafting </li></ul></ul>
  19. 19. Alveolar Bone Graft Technique Incision and flap design for unilateral cleft defect repair
  20. 20. Alveolar Bone Graft Technique Elevation of labial and buccal mucoperiosteal flaps
  21. 21. Alveolar Bone Graft Technique Creation of labial and palatal flaps after excision of intradefect fistula
  22. 22. Alveolar Bone Graft Technique Buccal flap elevated superiorly Palatal flaps elevated and pushed posteriorly
  23. 23. Alveolar Bone Graft Technique Closure of nasal floor mucosa superiorly ( NF ) and palatal mucosa ( PM ) posteriorly NF PM
  24. 24. Placement of particulate cancellous bone into defect Alveolar Bone Graft Technique
  25. 25. Alveolar Bone Graft Technique
  26. 26. Alveolar Bone Graft Technique Labial pedicled “finger” flap elevated to cover bone graft as alternative to sliding buccal mucoperiosteal flap
  27. 38. Preoperative Cleft Defect Postoperative Bone Graft