Secondary Alveolar Bone Grafting is a procedure used in patients with cleft alveolus to maintain adequate and good arch size and shape , provide support for nasal base, to provide adequate bone stock for canine eruption

1. SECONDARY ALVEOLAR BONE GRAFTING
DR. K. KRISHNA LOHITHA , II MDS
DEPT. OF ORAL & MAXILLOFACIAL SURGERY

2. CONTENTS
 INTRODUCTION
 HISTORY
 DEVELOPMENT OF ALVEOLAR BONE
 ANATOMY OF ALVEOLAR CLEFT
 GOALS
 TIMING
 RATIONALE
 PATIENT HISTORY AND PHYSICAL EXAMINATION
 RADIOGRAPHIC INVESTIGATIONS
 PRESURGICAL PREPARATION OF PATIENT
 DIFFERENT GRAFTS USED
 SURGICAL TECHNIQUE
 COMPLICATIONS

3. INTRODUCTION
 Treatment of the child with cleft lip and palate
begins with the considerations primarily directed
towards cosmetic repair of lips and nasal
deformities and functional repair for lip musculature
and palate.
 Concern over the cleft in region of alveolar process
is often recognised later.
 The osseous closure of the alveolar cleft,is required
for the formation of a regular upper dental arch,
occupies a special position within the whole
concept of cleft lip and palate therapy.

4. HISTORY
1901 – Von Eiselberg: Used pedicled flap (bone of
little finger) to fill alveolar cleft.
 In 1908 – Lexur: Free bone graft in cleft
 1914 – Drachter: Ist successful bone graft using
tibial bone and periosteum.
 1931 – Veau: Classification of cleft & attempted
tibial bone graft in alveolar cleft.
 1950 – Schmid: Successful ABG using iliac bone
graft
 1955 – Johanson & Nordin: Primary ABG using
tibial bone in a stage procedure lip, palate, alveolus
– closure by 1 yr of age.

5.  1960 – Schuchardt & Pfeifer: Primary ABG using rib
graft at the time of lip closure.
 1960’s- Scoog: bonless bone grafting- GPP
 1964–Pruzansky: Bone grafting should be delayed
until after eruption of permanent dentition
 1968–Jolley: Detrimental effects of early bone graft
on maxillary growth
 1972–Boyne&Sands: Protocol for secondary ABG
 1981- Abyholm: SABG
 1983–Wolfe et al: Favourable result with calvarial
bone
 1987–Nique&Fonseca: ABG with allogenic bone
 Alveolar segmental osteotomies
 Alveolar distraction osteogenesis

6. DEVELOPMENT OF ALVEOLAR BONE
Cleft Alveolus due to
 Failure of fusion of MNP & maxillaryprocess
 Ossification centres in the premaxilla & maxilla
cannot migrate & fuse cause cleft alveolus
 Vertical growth still active upto 9-10 years
 Transverse & AP Growth 95% Completed at 8yrs.

7. ANATOMY OF ALVEOLUS
 The alveolar cleft is more than a linear gap in the maxillary arch.
 With soft tissue removed, the cleft is best visualized as a tornado,
increasing in size from incisal to apical, becoming widest as it
extends into the nasal cavity and distorts the surrounding anatomy
 Cleft patients with a permanent osseous defect of the alveolar arch
and maxilla will, even after the best surgical and orthodontic
treatment, be left with the following deficiencies:
1. Limited prospects for orthodontic treatment. The osseous defect
makes a nonprosthodontic dental rehabilitation impossible and
necessitates a dental bridge to close the gap in the dental arch.
2. Instability of the maxillary segments, particularly of the premaxilla in
bilateral clefts.
3. Oronasal fistulae or mucosal recesses that impede
oral hygiene.
4. Insufficient support of the alar base contributing to
the nasal asymmetry.

9. GOALS OF TREATMENT OF THE ALVEOLAR CLEFT
 Stabilisation of maxillary arch
 Separation of oral and nasal cavities
 Appropriate maxillary arch form and transverse width
 Stable environment for eruption of cleft-side canine
 Maintenance and bone support of all erupting teeth
 Keratinized gingival environment for erupted teeth
 Piriform bone support of nasal base
 Preserved anterior vestibule
 Uninhibited facial growth
 Minimized donor site morbidity
 Provision of adequate bone stock for implant placement

10. TIMING OF ALVEOLAR BONE GRAFTING
 < 2 Years of Age: Primary Grafting
After lip repair
Before palate repair
 ≥ 2 Years of Age: Secondary Grafting
Age in years
2–5: Early secondary
6–12: Mixed dentition secondary (after central incisor
eruption and before the canine erupts)
6–8: Early mixed dentition
9–12: Late mixed dentition
> 12: Late secondary grafting

11. PRIMARY BONE GRAFTING
 AIM: Acheive early
stabilisation of maxilla
Obliterate oro antral
fistulae
In bimaxillary clefts, pre
maxillary setback
INDICATIONS:
elimination of bone deficiency
stabilisation of pre maxilla
creation of new bone matrix
augmentation of alar base
CHOICE OF GRAFT: Rib
ADVANTAGES:
 Improved arch forms
 Decreased incidence of arch
collapse
 Decreased need for
orthognathic surgery
 Preservation of lateral incisor
Disadvantages:
 Decreased midfacial growth
 Inadequate bone formation
 Rib harvest morbidity
 Need for bone grafting later
in life

12. Long term studies show that:
• abnormal maxillary development with maxillary retrognathia,
Reasons for Maxillary Growth Disturbance
 Disruption of vomer – premaxillary suture
 Extensive mucoperiosteal stripping
 scar formation
 Vomerine flap disruption
• concave profile,
• increased frequency of crossbite compared with patients
without grafts

13. EARLY SECONDARY ALVEOLAR BONE
GRAFTING
 2 – 6 years of age
 To provide support for eruption of laterals
Disadvantage
 Significant transverse growth and sagittal growth
may be affected
 Literature not support the early secondary grafting

14. SECONDARY ALVEOLAR BONE
GRAFTING
 9-11 years
 most commonly done before eruption of canine
 When ½ to 2/3rd of canine root has formed
 Only vertical growth remains at this age.
 Physiological migration & spontaneous eruption through
grafted bone observed
Pre requisites:
 Precise timing
 Operating technique
 Sufficiently vascularised soft tissue

15. RATIONALE FOR GRAFTING AND FOR TIMING OF GRAFTING
during this time period include the following:
 Minimal maxillary growth after age 6 to 7 years
 minimal to no alteration of facial growth
 Cooperation with orthodontic and perioperative care is
predictable.
 The donor site for graft harvest is of acceptable volume
for predictable grafting with autogenous bone
 Bone volume may be improved by eruption of the tooth
into the newly grafted bone
 allows placement of the graft before eruption of
permanent teeth into the cleft site – one of the primary
goals of grafting.
 Bone grafting when erupting teeth is still covered by a
thin layer of bone acheived greater alveolar height
 Prevents external root resorption

16. Factors Contributing to Timing of Grafting During
the Mixed Dentition
 Dental age vs chronologic age
 Presence of the lateral incisor
 Position of the lateral incisor
 Degree of rotation/angulation of the central incisor
 Trauma/mobility of premaxillary segment(bilateral
clefts)
 Social issues
 Size of the patient and of the cleft
 Occlusion
 Need for adjunctive procedures

17. LATE SECONDARY GRAFTING
Patients older than12 years of age who undergo grafting
have been reported
 to have decreased success when evaluated using the
Berglandscale,
 loss of osseous support of teeth adjacent to the cleft
 increased morbidity.

18. PRE VS POST SURGICAL ORTHODONTICS
 Controversy exists regarding the use of orthopedic
expansion of the cleft segments and the
relationship between expansion and grafting
 Most authors prefer presurgical expansion
because of
 less resistance,
 improved access to the cleft for closure of the
nasal floor,
 better postoperative hygiene
 less chance of reopening the oronasal fistula

19.  Orthodontic movement of the erupted teeth
adjacent to the cleft is another controversial topic
 Some authors suggest that aligning the teeth
adjacent to the cleft produces better hygiene and
an improved result

20. HISTORY & PHYSICAL EXAMINATION
Focused examination on:
 Any previous repair
 Oro nasal fistula
 Alar support
 Size of alveolar defect
 Mal positioned teeth in cleft region
 Alignment / cross bite of teeth
 Position & mobility of premaxilla
 Adequacy of soft tissue for tension free closure
 Oral hygiene

21. RADIOGRAPHIC EVALUATION
 OPG
 Occlusal view
 Peri apical view

22. PRE SURGICAL PREPARATION OF A PATIENT
 The Premaxillary Segment in bilateral case
stabilized by arch wire, Since mobile premaxilla will
cause the grafted bone fail to consolidate.
 Oral Hygiene Prophylaxis
 Ortho treatment -Correction of cross bite &
alignment of arch
 Supernumerary or Retained Deciduous teeth in
cleft area should be removed atleast 6 – 8 week
before surgery to ensure adequate width &
continuity of soft tissue flaps.

23. TREATMENT OPTIONS FOR CLEFT ALVEOLUS
 Bone grafting
 Gingivo periosteoplasty
 Distraction osteogenesis

24. GRAFTS FOR ABG
AUTOGENOUS
 Cancellous:ILIAC BONE
 Cortico- cancellous: ILIAC
 RIB
 TIBIA
 MANDIBLE
 Cortical: CALVARIUM
 SYMPHYSIS
ALLOPLASTIC
ALLOGENIC: BMP2

25.  CANCELLOUS BONE
 Forms on the surface of
pre existing trabeculae
 More vascular
 More osteogenic
potential
 Better ingrowth of new
bone from adjacent bone
segment
 Apposition followed by
resorption
 Greater mechanical
strength
 CORTICAL BONE
 Metabolic turnover and
remodelling is slower
 Resorption followed by
apposition
 Remains as a composite
of new and necrotic bone
 Prone to infections
 Not completely
vascularised upto 2
months

26. Site
 Iliac crest: gold standard for SABG
Advantages
 Large quantity of cancellous bone.
 Decreased operativetime with 2 team approach.
 No growth disturbance
 Easy to condense & pack
 Proven successful
Disadvantages
 Mild transient gait disturbance
 Donor site morbidity reported in literature
Consideration
 All clefts , particularly large & bilateral clefts

27. Site
 Proximal tibia
Advantages
•Adequate cancellous bone
 Minimal soft tissue dissection
 Two team approach
Disadvantages
 Mild post-op discomfort
 Less bone than iliac bone
 Interferes with growth(due to epiphyseal growth
Consideration
 Not recommended in patients that have not completed
growth

28. Site
 Rib
Advantages
 Two team approach possible
 Mainly used in primary ABG
Disadvantages
Poor source of cancellous bone
 Post-op-pain
 Visible scar
 Associated morbidity
 Unpredictable result
Consideration
 Not recommended except for primary grafting

29. Site
 Cranial bone
Advantages
 Incision hidden in hair
bearing area
 Minimal postop
 discomfort
Disadvantages
 Sparse cancellous bone
 Increased operative time
 Associated morbidity
 Poor results than ilium(less
cellular)
 Stigma & fear for patient
Consideration:
 Unilateral clefts: lower
success rate
Site
 symphysis
Advantages
 Same operative field
 Rapid post-op recovery
 No external scar
Disadvantages
 Sparse amount
of,cancellous bone
 Associated morbidity
 Poor result
Consideration:
 Older children with small
defects

30. Type
 Allogenic:
 derived from a genetically
unrelated member of
same
species(osteoconductive,
osteoinductive
Advantages
 Comparable to
autogenous
 Allows for eruption of
teeth
 Avoids donor site
morbidity
 No osteogenic potential
Disadvantages
 Delayed incorporation
Type
 Alloplastic: inert foreign
body
material(osteoconductive,
osteoinductive
Advantages
 Avoids donor site
morbidity
disAdvantages
 Delayed healing
 Inability of teeth to erupt

31. SURGICAL TECHNIQUE
 Three basic surgical principles must be satisfied for
the successful treatment of the alveolar cleft
grafting:
(1) closure of oronasal fistula,
(2) adequate volume of graft material,
(3) water tight and tension-free closure.

32. UNILATERAL ALVEOLAR CLEFT
Incision line for an oblique sliding flap
(dashed line)

33. The closure of the nasal mucosa
and the introduction of the bone
graft to the alveolar defect
Depiction of the nasal
mucosa flap along with the
closure of the oral mucosa

34. Final mucosal closure of the
oblique sliding flap.
A palatal splint placedmover the
closure area to prevent formation of
a hematoma andstabilize the bone
graft.

35. The grafted bone responds physiologically to
the erupting canine:
a Alveolar cleft prior to bone grafting.
b The canine erupting normally through the grafted bone

36. BILATERAL ALVEOLAR CLEFT REPAIR
A bilateral alveolar
cleft palate
Needle palpation of the
bony edges of the
alveolar cleft while
injecting local anesthesia

37. The incision line
(dashed line)
Elevation of the nasal mucosa
on the left and closure of the
nasal mucosa on the right.
Placement of the bone graft
over the closed
nasal mucosa.

38. Palatal depiction of the movement of the adjacent
mucosa in the oblique sliding flap technique

39. Mucosal closure in a bilateral alveolar cleft.

40. Final closure of the bilateral alveolar cleft repair using a
oblique sliding flap technique

41. POST-OPERATIVE INSTRUCTIONS
 Liquid diet 7 days
 Avoidance of trauma to the site
 Antibiotics & nasal decongestants
 Meticulous oral hygiene with chlorhexidine

42. COMPLICATIONS
 Failure of bone grafts (Mainly in mobile premaxilla)
 Infection
 Wound breakdown & loss of graft(incomplete
oral/nasal closure)
 External root resorbtion
 Bone loss
 Residual fistula

43. SUCCESS OF ABG
 Good nasal side closure
 Use of adequate amount of cancellous bone
 A water tight oral side closure
 Adequate amount of attached mucosa in the area
of cleft for development of normal periodontal
attachment of erupting canine

44. GINGIVO-PERIOSTEOPLASTY
 Boneless primary bone graft
 Relies on the osteoinductive
capabilities of the periosteum
If the alveolar anatomy and
presurgical molding outcome
are favorable, a GPP can be
offered to the family at the
same time as the primary lip
repair
Advantages
 Repairs the cleft in anatomic
way by a precise
reconstruction of the functional
matrix(mucoperiosteal matrix
of maxilla)
 Avoids the need for ABG

45. DISTRACTION OSTEOGENESIS
Advantage
 No need for bone graft
 No donor site morbidity
 Minimal surgical time
 Bone height & width similar to normal adjacent
alveolus
 Dental implants possible
 Final orthodontic tooth movement is good
 Minimal morbidity
Disadvantage
 Long treatment requires patient cooperation & close
follow-up

46. INDICATIONS
 “ungraftable” or “recalcitrant” alveolar clefts
 The typical patient who falls into this category has
unhealthy, scarred gingiva, a large nasolabial
and/or oronasal fistula, and a history of repeated
unsuccessful bone grafts with infections and
exposure.
 Another possible presentation is a previously
grafted maxilla that has severe vertical deficiency
along with scarred mucogingiva preventing
additional graft augmentation
 past mixed dentition due to the risk to unerupted
tooth follicles during the segmental osteotomies

47. HORIZONTAL TDO
 The principle is to create a transport segment by
separating an adjacent two- or three-tooth-bearing
segment of the distal alveolus from the maxilla
without damage to the tooth roots and without
violation of the attached gingiva

48. VERTICAL TDO
 Vertical alveolar TDO is useful for augmentation of
a previously grafted cleft when the gingiva or
previous surgeries have made augmentation with
standard grafting techniques not possible

49. CONCLUSION
 Although the repair of the alveolar cleft may be one
of the last considerations in the global treatment of
a cleft patient, if these goals are achieved, it
provides tremendous enhancement of oral function
and aesthetics for a cleft patient.

50. REFERENCES
 Peterson principles of oral and maxilofacial surgery :2nd edition
vol II
 OUTLINE OF ORAL &MAXILLOFACIAL
SURGERY- Peterwardbooth vol II
 Alveolar clefts ;Richard A. Hopper and Gerhard S. Mundinger
 Secondary Bone Grafting of Alveolar Clefts Frank E.AbyholmOral
Maxillofacial Surg Clin N Am 14 (2002) 477–490
 Alveolar bone grafting;Jan Lilja; SwedenIndian J Plast Surg
Supplement 1 2009 Vol 42
 Grafting materials for alveolar cleft reconstruction: a systematic
review and bestevidence synthesis
 Management of Alveolar Clefts Using Dento-osseous Transport
Distraction Osteogenesis;Angle Orthodontist, Vol 73, No 6, 2003