This document discusses the timing and techniques for alveolar bone grafting in patients with cleft lip and palate. It recommends primary alveolar bone grafting before age 2 and secondary grafting between ages 6-15. The goals of grafting are to provide bone and tooth support, restore ridge height, and obliterate oronasal fistulas. Autogenous bone from the ilium or tibia is typically used as it induces the most new bone growth. Proper technique and blood supply to the graft are essential for successful bone regeneration.

2. Any patient born with complete cleft should
be considered for alveolar grafting.
Cardinal rule

3. Based on the timing of grafting ,
 Primary - less than 2 yrs.
 Early secondary - 2-5 years.
 Secondary - 6-15 years.
 Late secondary - >15 years.

4.  Primary repair – before palatal closure.
 Secondary repair – after palatal closure.

5. “….a surgery that is needless and sometimes
barbaric……”
-Pruzansky
In , 1963 Convention of American Cleft
Palate Association.

6. Robertson and Jolly (1968) –first to report
mid-face deficiency and malocclusion due to
primary repair.
Transverse maxillary arch collapse is not
completely prevented by primary repair.

7. Koberg states that,
“……most severe maxillary deformities are to
be expected as late results of primary bone
grafting , so that late secondary osteoplasty
remains the only justifiable form of bone
transplantation in cleft surgery……”

8.  Max arch stabilization,
 Bony support to teeth adjacent to cleft,
 Provision of bone for tooth eruption & ortho
movement,
 Ridge height for prosthetic rehabilitation,
 Obliteration of oro-nasal fistula,
 Support for alveolar base.

9.  Palatally displaced alv.ridge on cleft side wit
tooth malalingment.
 Deficient bone support.
 Inadequate oral hygiene, due to oro-nasal
fistula.
 Segmental mobility.
 Effects on speech.

10.  Grafting.
1.autogenous 2.allogenous 3.alloplastic
 Orthognathic surgery.
 Intradental distraction osteogenesis.
 Periosteoplasty.

11. Phillip J. Boyne & Ned R. Sands journal of oral
surgery feb1972, vol 30, 87-92.
CLASSIC ARTICLE.
Prefered time for surgery-btwn 9 and 12 years.

12. But , dental developmental age, and not the
chronological age is the foremost consideration.
grafting is done → canine root is 1/4th to 2/3rd
complete.
“delaying grafting beyond the point of canine
root development → increased incidence of
periodontal defects and fistula.”
Sindet – Pederson - Enmark

13. When orthognathic surgery is planned …
Secondary grafting is delayed.

14. In autogenous group , bone is deposited in 2 to
6wk . At 6th mo complete bone fill.
In allogenous group , host bone induction was
not there till 7th wk .At 6 mo only 30% bone
filling was evident.
-Marx .et al, JOMS 42 ; 3 ,1984.

15.  Currently alloplasts are indicated for only
ridge contouring & not indicated in growing
individuals & wit unerupted tooth adjacent to
cleft & only wen endosteal implants are not
planned.

16. Optimal sequence…
Transverse expansion of
maxilla (in late mixed
dentition)
Followed by bone grafting

17. Graft procurement site selection is based on …
 Primarily , size of the defect.
 Age of the patient.
 Operator preference.
 Patients desire.

18. “best inductor agent…..is natural human bone
of cancellous structure in finely divided form ,
and that the most responsive tissue is the
connective tissue closely related to living
bone…”
-Collins ,Pathology of Bone.

19.  Illium.
 Calvarium.
 Mandibular symphysis.????
 Rib.
 Proximal tibia.

20. Best cancellous grafts obtained from
Trochanter major(femur)
-Spiessl, oral & maxillofacial bone surgery.
PCBM – Particulate Cancellous Bone Marrow
grafts, obtained from illiac crest is the donor
material of choice.
-Boyne & Sands 1972

21.  Existence in unlimited supply.
 Provision for immediate osteogenesis for rapid
consolidation.
 No adverse host rxn.
 immed. revascularization
 Osteoinduction
 Adaptability .
 No impediment in growth.
 Framework for osteoconduction.
 Completely replaceable by bone.

22.  Restores normal continuity & functions.
 Restores appearance and facial esthetics.
 Forms allostructural framework for new bone
formation.
 Furnishes osteogenic cells.
 Precursor for bone induction principle.

23.  Adequate blood supply of recipient site.
 Bone to bone contact ,CREEPING SUBSTITUTION.
 Rigid fixation of fragments.
 Grafts to be placed into only healthy tissue..

24. Cell viability
 Best maintained in culture media/N.S.
 95% viability at room temp for 4 hrs.
 temp of solution death rate of cells.
 Temp cooler than room temp small in cell
survival.
 Avoid hypotonic sols.
10cc loose uncompressed cancellous bone
for every 10mm length of reconstruction.