Alveolar Bone Grafting.

Frederick Mars Untalan MD
http://entmdclinic.blogspot.com/ 1
 Rationale
 Definition of terms
 Type of Bone and Donor Site
 Techniques
400 %
300 %
> 500,000 bone graft procedures / year

 Vast number of :
• Dental/maxillofacial 46%
• Basic Science/Animal 25%
• Spine 11%
• Small series 5%
• Review articles 14%
 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
 Repair of Cleft Lip and Palate A Parent's Guide Susan M. Revesz, M.S.N., R.N. M. Haskell
Newman, M.D. Karen L. Holtsberry, B.B.A. C.S. Mott Children's Hospital, Craniofacial
Anomalies Program University of Michigan Medical Center
 Background: The contemporary treatment of cleft lip and palate involves a sequence
of surgical procedures and orthodontic management. Alveolar bone grafting (ABG) is
usually undertaken after orthodontic expansion of the maxillary segments between
the ages of eight and 12 years. Two of the important goals of alveolar bone grafting
are the provision
canine of bony
root support for the eruption
development and of the caninecontinued
eruption and the closure of
residual oro-nasal fistulae. The purpose of this study was to retrospectively evaluate
satisfactorily through
the root development grafted
and eruption alveolar
of the canine clefts
following ABG.in most cases
 Methods: Group 1: radiographic and clinical records of a sample of 19 cleft patients
and closurealveolar
who underwent of anterior oro-nasal
bone grafting fistulae
procedures, performedwas achieved
between 1996 andin
1999 were reviewed. Group 2: a random sample of 15 cleft patients attending for
all
routine dental review were clinically cases.The age of patient, degree of root
examined.
development and eruption status of the canine, and presence of oronasal fistulae pre
and post alveolar bone grafting were evaluated.
 Results: Most cleft canines had continued root development and descended in the
alveolus towards eruption following ABG. Four canine teeth (8 per cent) were
impacted and required surgical exposure and orthodontic treatment following failure
of eruption. Closure of anterior oro-nasal fistulae at the time of grafting was
maintained post-operatively.
 Conclusions: This study demonstrated that canine root development and eruption
continued satisfactorily through grafted alveolar clefts in most cases and closure of
anterior oro-nasal fistulae was achieved in all cases.
 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
 Secondary Bone Grafting
 Early
 Intermediate (Secondary)
 Late
 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
 Performed most commonly
 Particulate autogenous cancellous bone
most common graft

 No observed growth disturbance
 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
 Done after eruption of the permanent
canine
 Usually during adolescence or adulthood
 Sometimes done concomitantly with
orthognathic surgery
 Popular in the 1950’s -60’s
 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
 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.
 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
 Management of Alveolar Clefts Anureet K. Bajaj, MD,Amnart A. Wongworawat, MD,Anil
Punjabi, BDS, DDS, MD Loma Linda, California
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

A three-dimensional growth disturbance after
The primary gingivoperiosteoplasty by Millard consists of presurgical active orthognathic
treatment (‘Latham device’) of the alveolar margins at the age of 3 months and of surgical closure
of the alveolar cleft with local gingivoperiosteal flaps at the age of 5 months.
gingivoperiosteoplasty was observed: 42% patients
 The aim of this investigation was to analyse the facial growth following this treatment.
 The following material was studied: lateral head X-rays and plaster casts from 146 patients with
with UCLP and 40% patients with BCLP had an ‘open
unilateral (UCLP) and bilateral (BCLP) clefts of lip and palate from birth to 16 years of age. Ninety-
one of these patients formed the control group, who received neither gingivoperiosteoplasty nor
bite’ following closure of the alveolar cleft (control
pre-surgical active orthognathic treatment. The same surgeon and orthodontist treated all 146
patients.
 A three-dimensional growth disturbance after gingivoperiosteoplasty was observed: 42%
group 5%/10%)
patients with UCLP and 40% patients with BCLP had an ‘open bite’ following closure of the
alveolar cleft (control group 5%/10%). The length of the upper jaw in patients who underwent
gingivoperiosteoplasty was shorter than in the control group. The frequency of posterior cross
bite was also higher in the gingivoperiosteoplasty group.
 The length of the upper jaw in patients who
These results demonstrate that treatment with a ‘Latham device’ disturbs facial growth.
Therefore, this treatment should be abandoned.
 underwent
K.-O. Henkel and K.K.H.gingivoperiosteoplasty
Gundlach was shorter
 Department for Maxillofacial Surgery (Head: Prof. K. K. H. Gundlach) Rostock University, Germany
than in the control group. The frequency of
posterior cross bite was also higher in the
gingivoperiosteoplasty group.
 Aim. The study evaluates the repair of residual alveolar cleft through secondary bone graft,
consisting in the transplantation of autologous bone to restore the continuity of the maxillary
arch and achieve normal functioning and esthetics.

the repair of residual alveolar cleft through secondary
Methods. During 2001-2002, 15 patients (age range 9-26 years; 7 males, 8 females) were
bone graft, consisting in the transplantation of
submitted to secondary bone graft at the Maxillo-facial Surgery Operative Unit, University
Hospital, Sassari. Eleven patients had complete unilateral cleft, 4 had complete bilateral cleft. All
autologous bone
patients were operated upon by the same surgeon; they received a graft of autologous bone from
the iliac crest. For preoperative and postoperative evaluation at 1 year, the following were
utilised: plaster casts of the tooth arches, OPT, photographs and complete clinical
documentation.
 Results. Postoperative results were: 100% formation of a bone bridge between the maxillary
This method was found to be the most valid one at
segments; 70% closure of oro-nasal fistula; 100% maxillary stability; 80% spontaneous eruption of
the canine within the graft; 70% height of alveolar ridge level I, 25% level II, 5% level III; 70%
present. The best period to intervene is during late
orthodontic closure; 80% optimal periodontal condition and 20% presence of gingival recession.
In 1 subject the graft site became infected, in 4 cases an oro-nasal fistula remained.
childhood (9 years). Results and functional and esthetic
 Conclusion. This method was found to be the most valid one at present. The best period to
recovery
intervene were
is during satisfactory
late childhood andandencouraging
(9 years). Results torecovery
functional and esthetic continue
were
satisfactory and encouraging to continue utilising this technique.
utilising this technique.
 MINERVA STOMATOLOGICA Minerva Stomatologica 2004 October;53(10):571-80 De Riu G., Lai V., Congiu M., Tullio A.
 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)
COMPARISON OF GRAFT SOURCES
site advantage disadvantage consideration

large quantity cancellous bone; all clefts, particularly large
ilium two teams mild transient gait disturbance & bilateral clefts
minimal posoperative
discomfort; incision hidden; low limited cancellous/diploic bone; unilateral clefts; lower
calvaria morbidity increased operative time success
mandibular same operative field; rapid older children with small

symphysis procurement; minimal pain limited bone defects
poor source cancellous bone;

postoperative pain; visible scar; not recommended except
rib two teams risk of pneumothorax for primary grafting
abundant cancellous bone; not recommended in

proximal easy procedure; mild patients that have not
tibia postoperative pain; two teams - completed growth
large quantity cancellous all clefts, particularly

ilium bone; two teams mild transient gait disturbance large & bilateral clefts








mandibular same operative field; rapid older children with

symphysis procurement; minimal pain limited bone small defects


tibia postoperative pain; two teams
http://entmdclinic.blogspot.com/ - completed growth 32


poor source cancellous bone; not recommended

postoperative pain; visible except for primary
rib two teams scar; risk of pneumothorax grafting

tibia postoperative pain; two teams
http://entmdclinic.blogspot.com/ - completed growth 33
large quantity cancellous bone; two all clefts, particularly large &
ilium teams mild transient gait disturbance bilateral clefts
minimal posoperative discomfort; limited cancellous/diploic bone; unilateral clefts; lower

calvaria incision hidden; low morbidity increased operative time success


postoperative pain; visible scar; risk of not recommended except for
rib two teams pneumothorax primary grafting
abundant cancellous bone;
easy procedure; mild not recommended in
proximal postoperative pain; two patients that have not
tibia teams - completed growth
• Autograft
• Growth Factors
• Allograft
• Biosynthetic
• Composite
• Future?
 GOLD STANDARD
• Osteoconductive
• Hydroxyapatite ,
Collagen
• Osteoinductive
• BMP, TGF-B, ect
• Osteogenic
• Osteoprogenitor cells
 LIMITATIONS
• Limited Quantity
• Limited Structure and shape
• Variable osteogenic
potential
• DONOR SITE
MORBIDITY- 2-35%!
 Bone grafting plays an important role in the dental rehabilitation of
patients with alveolar cleft. During the period between 1993 and 2001, 12
patients Cancellous
with alveolar cleftsiliac bone
have been treatedgrafts
in our clinic. Cancellous
iliac bone grafts were used in all 12 patients. Seven patients had left and
five patients had right complete unilateral cleft lip and complete cleft
palate operations. All patients had palatal fistulas. The ages were
between
This 4 and 18 years procedure
surgical (mean age, 10.5achieves
y). Seven of successful
them were female
(58.4%) and 5 were male (41.6%). All the cancellous grafts survived.
results
Enough if itthe
filling and is closure
used of with the proper
the fistulas indication
were achieved except one
patient who had wound dehiscence and partial graft loss. The patients
experienced a limp for 2in suitable
days cases.
(mean time) because of the donor site. This
surgical procedure achieves successful results if it is used with the proper
indication in suitable cases.
 Journal of Craniofacial Surgery. 13(5):658-663, September 2002.
Bilkay, Ufuk MD; Tokat, Cenk MD; Ozek, Cuneyt MD; Gundogan, Hakan MD; Gurler, Tahir MD; Tegsel, Zuhal
MD; Songur, Ecmel MD
 Background: Traditional practice for alveolar cleft closure requires postoperative hospital convalescence in an
unfamiliar, disruptive hospital setting. An outpatient iliac crest alveolar bone grafting protocol was devised to
optimize patient care.
 Alveolar cleft bone grafting using the iliac crest
Methods: A retrospective review of the senior author's experience over 5 years (1998 to 2004) of ambulatory
alveolar cleft closure was compared with the previous 5-year period (1993 to 1998) of inpatient convalescence.
donor site can be safely performed on an
An iliac crest donor site and standard techniques of alveolar grafting were followed in both groups. Although
local analgesia with lidocaine and epinephrine was used in both groups, the ambulatory group received
preemptive local anesthesia augmented with Marcaine. Postoperative nausea also was treated preemptively in
outpatient basis when local pain control is followed
the outpatient group with the addition of dexamethasone (Decadron) and ondansetron (Zofran), whereas the
control patients were treated as needed. Patient charts were reviewed for demographic information, technical
aspects, length of donor-site incision, bone graft volume, and time of operation. A Fisher's exact test was used

by predictable anesthetic recovery and sufficient
for statistical analysis. Complications including morbidity, readmission, and reoperations were recorded.
Results: Twenty consecutive patients were treated on an outpatient basis. Eight consecutive patients were
oral intake, and reliable motivated parents or
convalesced as inpatients in the previous 5-year period. The ambulatory series average patient age was 12.1
years (range, 8 to 15 years). Four bilateral proce-dures were performed. The follow-up period averaged 3.5 years
(range, 5 to 76 months). Two minor complications were identified: cellulitis at a donor site and a recipient suture
caregivers provide a comfortable postoperative
line dehiscence with minor graft exposure. There were no readmissions, revision operations, hernias, wound
infections, or graft losses identified. In the inpatient series, the average stay was 1.8 days (range, 1 to 3 days).
One gingival suture line dehiscence requiring no further intervention was identified, for an average complication

setting.
rate of 12.5 percent, which was not significant compared with the ambulatory group (10 percent) (p = 1.00).
Conclusions: Alveolar cleft bone grafting using the iliac crest donor site can be safely performed on an outpatient
basis when local pain control is followed by predictable anesthetic recovery and sufficient oral intake, and
reliable motivated parents or caregivers provide a comfortable postoperative setting. Safe outpatient surgery
provides patients and family the opportunity to recover in the familiar home environment.
 Plastic and Reconstructive Surgery: 1 September 2005 - Volume 116 - Issue 3 - pp 736-739
 Perry, Charles W. M.D.; Lowenstein, Adam M.D.; Rothkopf, Douglas M. M.D
 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
 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
The ideal technique will meet the following criteria:
 Predictable closure of the nasal floor produces a watertight barrier
between the graft and the nasal cavity
 There is access to closure of residual palatal and labial fistula
 Keratinized attached tissue is maintained around the teeth adjacent
to the cleft and in the site where the yet unerupted lateral incisor and
caninewill erupt
 Mobilization of tissue is adequate to close large defects without
tension,when such defects are present
 The vestibule is not shortened, and scarring is not excessive
Hall HD, Posnick JC. Early results of secondary
bone grafts in 106 alveolar clefts. J Oral
Maxillofac Surg 1983;41:289–94.
Incision and flap design for Sulcular incision are used to develop sliding flaps
unilateral cleft defect repair
Elevation of labial and Creation of labial and palatal
buccal mucoperiosteal flaps after excision of
flaps intradefect fistula
Palatal flaps are developed sharply with
Buccal flap elevated scissors. This also separates the nasal mucosa
superiorly from the palatal tissue.
Palatal flaps elevated and
pushed posteriorly http://entmdclinic.blogspot.com/ 47
NF
PM
Palatal closure .This can be done before

Closure of nasal floor mucosa superiorly
or after the nasal mucosa is closed
(NF) and palatal mucosa (PM) posteriorly
Nasal mucosal flaps are reflected
from the bony walls of the cleft.
Nasal flaps are approximated with
sutures burying the knots when possible
Bone is packed into the defect with a periosteal
elevator or orthodontic band pusher. Digital
Placement of particulate cancellous
pressure against the palatal flap facilitates
bone into defect
packing and protects the palatal closure
The labial flaps are advanced toward each other and closed. This provides
attached keratinized tissue. Exposed areas distally where the flaps have been
advanced are left to granulate
Labial pedicled “finger” flap
elevated to cover bone graft as
alternative to sliding buccal
mucoperiosteal flap
Bone in a healthy person will adapt to
the loads it is placed under.
If loading on a particular bone
increases, the bone will remodel itself
over time to become stronger to resist
that sort of loading.
The external cortical portion of the bone
becomes thicker as a result.
Frederick Mars Untalan MD

Alveolar Bone Grafting.

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Frederick Mars Untalan MD

> 500,000 bone graft procedures / year

most common graft

site advantage disadvantage consideration

mandibular same operative field; rapid older children with small

poor source cancellous bone;

abundant cancellous bone; not recommended in

site advantage disadvantage consideration

large quantity cancellous all clefts, particularly

mandibular same operative field; rapid older children with small

poor source cancellous bone;

abundant cancellous bone; not recommended in

site advantage disadvantage consideration

mandibular same operative field; rapid older children with small

poor source cancellous bone;

abundant cancellous bone; not recommended in

site advantage disadvantage consideration

mandibular same operative field; rapid older children with

poor source cancellous bone;

abundant cancellous bone; not recommended in

site advantage disadvantage consideration

mandibular same operative field; rapid older children with small

poor source cancellous bone; not recommended

abundant cancellous bone; not recommended in

site advantage disadvantage consideration

minimal posoperative discomfort; limited cancellous/diploic bone; unilateral clefts; lower

mandibular same operative field; rapid older children with small

poor source cancellous bone;

 After Alveolar Bone Grafting

Palatal closure .This can be done before

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