Alveolar Bone Grafting

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Alveolar Bone Grafting

• Jaime Gateno, DDS, MD
• Associate Professor
• Oral and Maxillofacial Surgery

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Alveolar Bone Grafting

• Rational
• Age
• Type of Bone and Donor Site
• Timing of Maxillary Expansion
• Techniques

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Alveolar Bone GraftingRational

• 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

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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

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Definitions

• Secondary Bone Grafting
• Early
• Intermediate (Secondary)
• Late

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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

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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

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Late Secondary Bone Grafting

• Done after eruption of the permanent canine
• Usually during adolescence or adulthood
• Sometimes done concomitantly with orthognathic
  surgery

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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

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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 3599, 1991.

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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
  1641-53, 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 3391, 1996

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Primary Bone Grafting
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Primary Bone Grafting
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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 3417-20, 1997 Carstens
MH Functional matrix cleft repair principles
and techniques. Clin Plast Surg 31159-189, 2004
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Secondary Bone Graft

• Performed most commonly
• Particulate autogenous cancellous bone
• most common graft
• No observed growth disturbance

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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)

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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 47946-952, 1989

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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

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