Cleft lip & palate treatment

Alveolar Bone Grafting

Secondary bone grafting into the alveolar cleft – goals, timing, technique and aftercare.

Summary

Secondary alveolar bone grafting is an operation in which bone – usually taken from the iliac crest – is grafted into the alveolar cleft. It is ideally performed at 9–11 years of age, before the canine attempts to erupt through the cleft. The goals are: to provide bone for canine eruption, to stabilise the nasal region and to restore continuity of the upper jaw.

Why and when?

Timing

Goals and timing of surgery

In children with cleft lip and palate, the upper jaw bone is missing a portion in the area of the dental arch. Without bone, the canine (tooth 3) cannot erupt properly, the palate is unstable and the nasal tip lacks bony support.

Ideal timing

For secondary alveolar bone grafting, the guideline is a canine eruption stage of ½ to ¾ root development – in most children this corresponds to age 9–11. This moment is monitored orthodontically and radiologically.^[1]

Too early (before ½ root development): poorer integration, possible growth disturbances
Too late (after full eruption without bone): the canine lacks bony support, markedly poorer prognosis

Secondary vs primary Primary bone grafting (in infancy, rare today) has been largely replaced by the secondary form, as it has fewer negative effects on jaw growth. The secondary form described here is today's standard.

Surgical technique

How is the procedure performed?

Preparation

Orthodontic preparation (3–6 months before surgery): expansion of the upper jaw (possibly with a palatal expander) for optimal space; oral hygiene check.

Bone harvest

Iliac crest harvest (crista iliaca). Cancellous bone is taken from the anterior iliac crest under general anaesthesia. Alternatives: calvaria (skull bone), rib cartilage, synthetic bone substitutes.

Grafting

Placement into the alveolar cleft. Periosteal flaps and mucosa are mobilised, the bone is placed and the wound closed without tension. The procedure takes about 1.5–3 hours.

Inpatient stay

1–3 days in hospital. Pain management, mouth rinses, soft/liquid diet for 4–6 weeks. Walking initially limited (hip pain at the harvest site).

Aftercare

Orthodontics guides the canine through the grafted bone. Radiographic check after 3–6 months to assess bone integration.

Evidence & outcomes

What does the literature show?

Secondary alveolar bone grafting with an iliac crest graft is considered a well-established technique with high success rates when timing is optimal:^[2]

Bone bridge formation in about 70–90 % of cases (the range varies by study and centre)
Canine eruption through the grafted bone succeeds in most cases with orthodontic support
Poorer outcomes with: unfavourable timing, large defects, insufficient orthodontic preparation, poor oral hygiene^[3]

Alternatives to iliac bone Synthetic bone substitutes and growth factors (e.g. BMP-2, rhBMP-2) are being evaluated in studies. Clear superiority over the iliac crest graft has not yet been demonstrated. The choice of material depends on centre experience, cleft size and patient age.

References

Bergland O et al. (1986). Elimination of the residual alveolar cleft by secondary bone grafting. Cleft Palate J, 23(3):175–205. PMID: 3524905
Rawashdeh MA, Telfah H (2008). Secondary alveolar bone grafting: the dilemma of donor site selection. Br J Oral Maxillofac Surg, 46(8):665–70. DOI
Enemark H et al. (2001). Secondary bone grafting in unilateral cleft lip and palate patients. Int J Oral Maxillofac Surg, 30(6):472–8. DOI

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