Secondary alveolar bone grafting

SECONDARY ALVEOLAR BONE GRAFTING
- SEMINAR BY TEJASWINI PSS, PG - III

 Embryology
 Treatment goals & objectives
 Timing of alveolar cleft repair & grafting
 Patient evaluation & assessment
 Source of graft
 Types of grafts
 Pre-surgical orthodontic care
 Preparation of cleft alveolus
 Types of tissue flaps used with bone grafts
 Post-op care
 Complications
 Post- surgical orthodontic care
 Other substitutes for bone grafting
 Case illustrations
CONTENTS :

 Cleft lip with or without cleft palate – 1 : 800 live births.
 Complete clefts - transverse the alveolar ridge 
disparate palatal segments
 The remaining alveolar defect following early lip and
palate repair requires grafting
Alveolar bone grafting

 The cleft of the alveolus was not initially perceived as a
problem on the same order as cleft lip
 Von Eiselberg’s - fifth digit to span the cleft in 1901.
 Initially, it was mostly performed in conjunction with
orthopedic appliances during deciduous dentition with
the goal of preventing maxillary collapse
 Pickrell et al 1968 - primary grafts did not grow with the
skull and that teeth did not reliably erupt into primarily
grafted clefts
  secondary grafting > primary grafting

 (1) the exact timing within the secondary period
 (2) the appropriate use of preoperative
orthodontic/orthopedic appliances
 (3) questions of technique and bone source
 (4) evaluation of bone graft outcomes.
Studies ON ABG focused on :

Alveolar Bone Grafting and Cleft Lip and Palate: A Review
Plast Reconstr Surg. 2016 Dec;138(6):12871295

 (Left) Alveolar bone grafting is optimally performed in the
stage of mixed dentition. (Right)
 Descent of the cleft-adjacent canine into the alveolar graft
puts functional stress on the graft to increase
 graft take and reestablishes normal dentition. (Created by
Jill K. Gregory, CMI, FAMI. Printed with permission
 from ©Mount Sinai Health System.)
(Left) Alveolar bone grafting is optimally performed in the stage of mixed dentition.
(Right)Descent of the cleft-adjacent canine into the alveolar graft puts functional stress on
the graft to increasegraft take and reestablishes normal dentition. (Created by Jill K.
Gregory, CMI, FAMI. Printed with permissionfrom ©Mount Sinai Health System.)

Treatment Goals And Objectives...

• Closure of oro antral fistula
• Establishing continuity between cleft segments
• Establishing proper alveolar contour
• Supporting tooth eruption and orthodontic movement of
teeth
• Providing for the periodontal health of teeth adjacent to cleft
• Providing support to the base of the nose and lip
• Facilitate nasolabial muscle and soft issue reconstruction
• Establishing functional airway
• Allow for placement of dental implants

Timing Of Alveolar Cleft Grafting

 Primary ABG : 0-2.5 yrs usually at the time of lip repair
 Early secondary ABG : 2-5 yrs before the eruption of
permanent incisors
 Secondary ABG : 6-13yrs before the eruption of permanent
canines
 Late secondary ABG : >13 yrs after the eruption of permanent
canines

Usually done at the time of lip repair
Disadvantages :
• poor maxillary growth
• negative effects on anterior and inferior growth of
maxilla
• inadequate contour of bone graft
• higher propensity for cross bites
Primary Alveolar Grafting

usually done in childhood before the eruption of permanent
incisors
 early surgery is not evaluated as thoroughly as late surgery
 Boyne indicated this when permanent central and lateral
incisors appear to be developing in such a direction that it
may erupt abnormally into the cleft resulting in inadequate
tooth position or severe malposition jeopardized bone
support because of anatomy of tooth eruption.
Early Secondary Bone Grafting

 classic time for alveolar grafting
Advantages :
 high percentage of good results
 allows eruption of canine
 healthy teeth on either side of cleft
 minimal impact on facial growth
 allows for orthodontic alignment
Secondary Alveolar Bone Grafting

Disadvantage:
 central and lateral incisors must have erupted
 carries increased risk of periodontal bone loss and root
resorption.
 Posnick mentions that waiting allows maximum
transverse growth of maxilla to occur before bone
grafting.
 95% of anteroposterior and transverse growth of
maxilla is completed by the age of 8yrs.

 It is done after the eruption of canine
 It has got lower incidence of successful grafts due to
poor oral hygiene and decreased blood supply or
altered oral flora in older children.
Late Secondary Alveolar Bone Grafting

Patient Evaluation And
Assessment :

Patient evaluated for any
 oronasal fistula
 caries
 malposed teeth
 state of occlusion
 oral hygiene
 mobility and position of pre maxilla
 adequacy of soft tissue for tension free closure

 Orthopantomograph
 Occlusal radiographs
 Periapical radiographs
 Cephalometrics in patients who have problems with
premaxillary position
Radiographic evaluation

Types of grafts :
Autogenous
grafts
Iliac crest
Tibia
Rib
Cranial bone
Mandibular symphysis
III molar region

 Eiselsberg ( 1901) made the earliest attempts to
transplant autogenous cancellous bone into cleft
maxilla, using little finger as a pedicled graft.
 Dracher used tibial bone and periosteum.
 Since then, usual sites for obtaining cancellous bone
grafts have included iliac bone, rib , calvarium.
 Sindet et al - chin bone as a graft.

 Studies on onlay grafts ( cortico-cancellous grafts ) :
Membranous bone superior to endochondral bone
 Embryological origin
 More cortical ; less cancellous  less resorption over time
 Studies on inlay grafts :
 Focused on maintainence of volume
 Endochondral ( ileum ) vs membranous ( symphysis )
 Studies on rabbit calvarium –
“Endochondral cancellous bone volume increased most over
time “
Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A.
Rawashdeh, H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

 Alveolar cleft :
 Osseous deformity
 Continuity defect of alveolar process & pyriform rim
 Reconstructed with bone inlayed between osseous
segments instead of onlay on maxilla
 Dynamics of inlay bone graft different from onlay grafts
Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh, H.
Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

Various factors affect the decision making process in
choosing an appropriate donor site for alveolar cleft :
 size of the cleft
 volume of bone needed
 whether teeth will erupt through graft material
 health of donor site
 healing potential of the patient

ILIAC BONE :
 Gold standard
 Easy access
 high success rates
 rapid bone formation and calcification ( large supply of
pleuripotent / osteogenic cells )
 Earlier cortico-cancellous blocks were used but lately only
cancellous bone is harvested using cylindrical punch with minimal
incision.
Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh, H. Telfah /
British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

 Cancellous bone graft > cortical graft
 high content of osteogenic cells
 Compacting : > no. of osteogenic cells
 Rapid revascularization of graft ( 3 weeks )

VARYING CONCEPTS OF BONE GRAFTING OF ALVEOALAR PALATAL DEFECTS- NICHOLAS et al, presented at 1963
convention of The American Cleft Palate Association, Washington DC

 The patient is in supine position
 iliac crest is made prominent by keeping a bolster under the
ipsilateral buttock.
 The ASIS, the iliac tubercle and the lateral and medial edges
of the iliac crest are marked
 local anesthesia for hydro dissection and hemostasis.
 The incision is placed marginally medial and away from the
ASIS to prevent damage to the lateral femoral cutaneous
nerve.
Preparation of Donor Site:

 While choosing the anteromedial approach care should
be taken to preserve the attachment of tensor fascia
lata.
 Disturbance of the tensor from the lateral crest will lead
to gait disturbances.
 In the lateral approach due to the tensor separation
there is gait disturbance and hence not very popular.
Anterior Iliac Crest Open:

 Donor site is exposed
 an opening is made using osteotomy (trap door or
open book type of exposure )
 The overlying cortical bone along with the cancellous
bone can be harvested or only the underlying
cancellous bone can be harvested using bone gouge.
 Closure
 The scar should be in a position where it doesn’t get
irritated away from the belt lines.

 The cancellous bone here is approached through a small
opening of around 1 to 1.5 cm using a drill or stab
incision and the cancellous bone is scooped out of the
bed.
 Advantages of the trephine technique are that the
postoperative pain, gait abnormalities and complications
are less common
Anterior Trephination:

 The posterior iliac crest can be approached for larger
quantities of bone.
 The use in intraoral oral procedures is limited due to the
fact that a prone position is required to harvest the
bone from the posterior ilium.
 This shifting the patient between recipient site
preparation and donor site harvesting is cumbersome.
Posterior Iliac crest approach

Disadvantages
• questionable effects on
growth
• possible gait disturbance
• post operative
hematoma
• donor site morbidity
Advantages
• adequate quantity
• easily condensed and
placed
• proven successful results
• little donor site
morbidity
• two team approach
Iliac crest graft

 Johanson and Ohlsson
 Drachter 1941 – facial clefts
 young infants of pre-weight bearing age.
 medial, slightly curved incision with excellent exposure of the
tibial shafts.
 large supply of cancellous bone is available.
 Cosmetically the post operative incision appears to be quite
acceptable.
TIBIAL BONE :

Disadvantages
 concern with ambulation
 epiphyseal injury
Advantages
 adequate volume
 quality similar to iliac
crest
 predictable results
 two team approach
Tibial graft

Disadvantages
 donor site morbidity
 unpredictable results
Advantages
 for infants
Rib grafts

Three techniques may be used for implanting the harvested
rib graft into the oral cavity
 An eccentrically placed H shaped rib strut is wedged into
the cleft with the more prominent portion facing the
labial side to elevate the depression caused by cleft.
 A solid piece of rib can be used following linear
separation at the ends exposing the cancellous part of the
bone.
 The rib can be broken into many small chips and packed
into the cleft

VARYING CONCEPTS OF BONE GRAFTING OF ALVEOALAR PALATAL DEFECTS- NICHOLAS et al, presented at
1963 convention of The American Cleft Palate Association, Washington DC

 Both cortical & cancellous bone
 Young patients
 Wolfe & Berkowitz – diploe from cranium for SABG
 Denny et al – curved osteotome + mallet ; shavings from
outer table & diploe
 Jacksen et al – craniotome technique ; powdered bone
run into slurry mixed with blood
Cranial bone :
Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh, H.
Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

Disadvantages
 donor site esthetics /defect
 stigma and fear for patient
 less cellular component
 difficult to harvest long
contoured strips like rib
graft
 difficult to obtain sufficient
cancellous bone
Advantages
 adequate quantity
 less resorption
(membranous bone )
 rapid vascularization
 predictable quality
 camouflaged scar
Cranial bone

 Hematomas
 Seromas
 Infected wounds
 Dural tears
 Subdural hemorrhage
 CSF Leak
Complications of cranial bone graft harvesting :

 Bosker & Von Dijt – mandibular symphysis
 Attractive donor site
 Low morbidity
Limitations :
 Limited volume
 increased percentage of impacted canines (increased
cortical content of the harvested bone)
 loss of unerupted permanent teeth early mixed dentition
 necrosis of the pulp, or devitalisation of teeth;
 injury to the mental nerve

Disadvantages
 limited amount of bone
 inability to remove bone
graft simultaneously with
preparation of recipient
site.
Advantages
 embryonic origin and
earlier vascularization -
superior maintenance of
contour
 less resorption
(membranous)
 no external scar

 may be indicated in late secondary grafting
 may be reasonable in young adults with small alveolar cleft.
III molar area

2 orthodontic considerations integrate with timing of alveolar
cleft grafting
 correction of cross bites
 alignment of anterior teeth
 cross bite due to narrowed transverse dimension of maxilla 
maxillary expansion performed before grafting
 when graft is performed before expansion 3 months should
elapse before expansion.
( full revascularization of cancellous bone takes place in 3weeks
but it takes 3months for bone to get complete trabecular pattern )

 bilateral cleft with a pre-maxilla  maxilla must be
expanded first before distalizaton of pre-maxilla to
ensure proper space.
 It is better not to begin teeth alignment before grafting
as movement of teeth adjacent to cleft may result in
root exposure through this alveolar bone in this area.

Five Principles in approaching the cleft alveolus:
 Wide exposure and appropriate Flap design.
 Reconstruction of Nasal floor closing the oro nasal
fistula
 Adequate graft material harvest.
 Adequate packing of the defect with cancellous bone
 Watertight closure of bone graft with gingival
mucoperiosteal flaps.
Preparation of the Cleft Alveolus:

Pre procedural consideration by the surgeon
 amount of mucosa available for closure
 best flap design to maintain adequate blood supply
 tension free closure
 extent of oro nasal communication
 level of support needed for the alar base
 donor site evaluation

An important factor  design of the flap
 preserve the maximum vestibular architecture
 provide maximum attached mucosa in the area of alveolar
cleft
 allow for normal periodontal sulcus and attachment of
permanent canine.
Procedure:

 A lateral angled relieving incision is placed into the gingival
sulcus on the cleft side.
 The muco-periosteum raised off the bone.
 The nasal layer is created on either side by incising around
the margin of cleft alveolus and mucoperiosteal flap is
pushed upwards till the depth of the vestibule to allow
bone graft.
 The cancellous bone is then packed into the cleft defect.
 Once packed the flaps are gently repositioned over the
sulcus and the cleft alveolus and sutured to ensure a
watertight closure.

A crevicular incision is placed through the sulcus of the
anterior teeth
 extending upto the first molar on the cleft side
 and on the non-cleft side two teeth lateral to the cleft
alveolus.
 A vertical relieving incision is placed on the cleft
alveolus side and there’s no release incision on the non-
cleft side.

Alveolar Bone Graft Technique
Incision and flap design
for unilateral cleft
defect repair

Elevation of labial
and buccal
mucoperiosteal flaps

Creation of labial and
palatal flaps after excision
of intradefect fistula

Buccal flap elevated superiorly
Palatal flaps elevated and
pushed posteriorly

Closure of nasal floor mucosa
superiorly (NF) and palatal mucosa
(PM) posteriorly
NF
PM

Placement of
particulate
cancellous bone into
defect

Labial pedicled “finger” flap elevated to
cover bone graft as alternative to
sliding buccal mucoperiosteal flap

 unilateral cleft alveolus - major palatine artery, anterior and
posterior superior alveolar artery and branches of
sphenopalatine arteries.
 In bilateral patients :
 union of superior labial arteries is non-existent
 blood supply to philtrum is grossly compromised
 deficient anastomosis of posterior septal artery and greater
palatine artery.
 The posterior septal artery and lateral (terminal branches of
anterior ethmoidal vessels) may contribute as they pass
through the columella.
Alveolar bone grafting in bilateral cleft:

 A variation of vessel on either side of the incisive foramen is
believed to tackle the compromised state.
 Thus it is prudent to modify the technique for bilateral
alveolus preparation.
 A common technique that can be employed is trying to
stage the two sides

LOCAL FLAPS :
 Local flaps obtained from the labial alveolar ridge and
rotated in a hinge like fashion based either medially or
laterally towards the palate exposing the bony segments of
the alveolar clefts.
 The labial defect is then closed with any of the labial flaps
which can be rotated from the medial or lateral side.
TYPES OF TISSUE FLAPS USED WITH BONE
GRAFTS :

DISTANT FLAPS :
 Distant flaps ( one stage vomer ) used for the closure of
wider alveolar clefts.
 It was used by Stellmach and Schrudde
 easily elevated and transferred in one stage directly
anteriorly to meet oncoming flap from the labial side.
 The denuded vomer can be covered with palatal pack for
24-48 hrs if necessary to minimize loosening if necessary.

 Bilateral vomer flaps used in bilateral clefts are formed
in two stages with intervals of two or three months as
 simulatenous denudation and elevation of two vomer
flaps  jeopardize the blood supply to vomer

 Avoidance of trauma to the site
 Avoidance of activities like swimming for 5-7 days
 Patient placed on antibiotics and nasal decongestants
for atleast 1week
 Meticulous oral hygiene with chlorhexidine mouth
washes
 Recognition and treatment of upper respiratory tract
infection
 Early ambulation

 Infection
 Wound dehiscence
 Loss of graft
 Incomplete closure of oronasal fistula
Complications

 3 months after the bone graft procedure
 depending on the radiographic image of the area 
orthodontic treatment is restarted to correct the position of the
permanent teeth.
 Teeth adjacent to the alveolar cleft - rotations & severe tipping
due to lack of adequate alveolar bone support.
 The pattern of eruption of the maxillary central incisor follows
the pattern of alveolar development in the cleft subjects.
 Dental alignments are possible if the alveolar cleft is grafted.

 Correction of malpositioned teeth – fixed / Semi-fixed or
fully bonded appliance  permitting adjacent teeth to
migrate or be orthodontically moved into the grafted bone.
 Often lateral incisor - congenitally missing, rudimentary or
malformed.
 canine brought into the space of the lateral incisor moving
the tooth through the alveolar bone graft and reshaped
into a lateral incisor and residual spaces closed with fully
fixed bonded appliance.
 Thus a complete dental arch can be obtained without
prosthodontics in the great majority of patients.

Ensuring Success in Alveolar Bone Grafting:
A Three-Dimensional Approach
- Cameron Craven, MD
The Journal Of Craniofacial Surgery / Volume 18, Number 4 July 2007

The alveolar and hard palate cleft should be viewed as a three
dimensional defect resembling a triangle or pyramid.

Schematic of incisions used to create gingivoperiosteal flaps
for coverage of the alveolar cleft.

Elevation of mucoperiosteal flaps from the medial and lateral margins of the
cleft. These are used to close the nasal floor and the roof of the oral cavity.

A) The alveolar cleft after packing with cortical and cancellous bone.
B) (B and C) Cortical bone reinforcing the roof of the cleft (nasal floor)
and the anterior wall of the alveolus.

Closure of the mucoperiosteal and gingivoperiosteal flaps with Vicryl
sutures.

Other Substitutes For Bone Grafting …
Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity
M.A. Rawashdeh, H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

 reduce morbidity
 not necessary to harvest autogenous bone,
 reduce the cost of rehabilitating patients with clefts.
 more than a century ago HCL demineralized bone chips
from ox tibia - implanted into canine cranial defects
Limitations :
 unpredictability in resorption / amount of bone formed
 Recently - recombinant human bone morphogenetic
protein (rhBMP)
Autogenous bony substitutes

 rhBMP-2  effective in the regeneration of alveolar bone
and associated periodontal attachment apparatus
 promotes the differentiation of pluripotential cells into bone-
forming cells that lay down new host bone in the site of the
defect (osteoinduction)
 remodelling equilibrium  prevents loss of bone through
resorption
 However, it requires a suitable carrier for its clinical
applications in human conditions to prevent rapid diffusion
of the protein
Recombinant human bone morphogenetic
protein (rhBMP).

 Boneless-bone grafting (gingivoperiosteoplasty) was popularized
by Skoog in the 1960s
 most widely debated
“if healthy periosteum is closed over the alveolar defect,
favourable osteogenic conditions would allow bone to bridge it “
 degree of ossification after gingivoperiosteoplasty varies
between 50% and 100%, and a third step of bone grafting may be
required.
Boneless-bone grafting
Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and
Morbidity M.A. Rawashdeh, H. Telfah / British Journal of Oral and Maxillofacial Surgery
46 (2008) 665–670

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