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Alveolar Bone GraftingAlveolar Bone Grafting
Jaime Gateno, DDS, MDAssociate ProfessorOral and Maxillofacial Surgery
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Alveolar Bone GraftingAlveolar 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 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
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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 3:599, 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 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
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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 34:17-20, 1997
Carstens MH: Functional matrix cleft repair: principles and techniques. Clin Plast Surg 31:159-189, 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
osteoconductionNique 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 alloplastHorswell 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
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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
NFNF
PM
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Placement of particulate cancellous bone into defect
Alveolar Bone Graft Technique
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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