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Google automatically generates html versions of documents as we crawl the web. 1 Alveolar Bone Grafting Jaime Gateno, DDS, MD Associate Professor Oral and Maxillofacial Surgery Alveolar Bone Grafting Rational Age Type of Bone and Donor Site Timing of Maxillary Expansion Techniques Alveolar Bone Grafting Rational 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 1950s -60s 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 osteoconduction 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 Alloplast Bone grows into, around alloplast No active osteoinduction but some osteoconduction Teeth do not erupt through alloplast 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

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 Graft Technique Incision and flap design for unilateral cleft defect repair Alveolar Bone Graft Technique Elevation of labial and buccal mucoperiosteal flaps Alveolar Bone Graft Technique Creation of labial and palatal flaps after excision of intradefect fistula Alveolar Bone Graft Technique Buccal flap elevated superiorly Palatal flaps elevated and pushed posteriorly Alveolar Bone Graft Technique Closure of nasal floor mucosa superiorly (NF) and palatal mucosa (PM) posteriorly NF PM Placement of particulate cancellous bone into defect Alveolar Bone Graft Technique Alveolar Bone Graft Technique Alveolar Bone Graft Technique Labial pedicled finger flap elevated to cover bone graft as alternative to sliding buccal mucoperiosteal flap Preoperative Cleft Defect

Postoperative Bone Graft