J Oral Maxillofac Surg

40:721-725, 1982
A Retrospective Study of Alveolar
Cleft Grafting
JAMES B. TROXELL, DDS, MS,* RAYMOND J. FONSECA, DMD,t AND
DONALD B. OSBON, DDS$
A surgical technique for the bone graft repair of alveolar clefts is described,
and an evaluation of the conditions of 30 patients who have undergone
that procedure is reported. Evaluation was made specifically for the pre-
operative and postoperative presence of oronasal fistula, postoperative
eruption of previously unerupted teeth into the graft, soft and hard tissue
periodontal status, and radiographic evidence of bone fill in the previous
cleft defect resulting in alveolar segmental stabilization.
Early alveolar bone grafting as part of the repair
of cleft palates was enthusiastically endorsed by
many workers in the late 1950s and early 196Os.-
The advantages cited were these: (1) control or fix-
ation of the maxillary arch with prevention of col-
lapse, (2) unit growth of the maxilla with eruption
and movement of teeth through the grafted bone,
and (3) proportional growth of the maxilla with the
mandible to maintain proper dental occlusion. Re-
pairs were performed in children from infancy to
age 2.
Early clinical follow-up studies began to show
less than satisfactory results, disagreements arose
about the reasons why the procedure did not fulfill
early expectations. Bone grafts of the alveolus were
frequently suggested to be the damaging element in
the overall cleft palate repair regimen. However, no
universal recording system was used, and the early
results from the different surgical centers often
presented conflicting findings. At the 1963 conven-
tion of the American Cleft Palate Association, Pru-
zansky referred to primary bone grafting as a
surgery that is needless and sometimes barbaric.
He pleaded for a concern for biological mecha-
nisms. Shortly thereafter, other reports appeared
that described unsatisfactory results, the greatest
objection being to the effects on maxillary growth.
4: Formerly Senior Resident in Oral and Maxillofacial Surgery:
now in private practice in Fort Collins, Colorado.
t Associate Professor and Director of the Residency Program
in Oral and Maxillofacial Surgery.
$ Full Professor and Chairman of the Department of Oral and
Maxillofacial Surgery.
Received from the University of Iowa Hospitals and Clinics.
Iowa City, Iowa 52242.
Address correspondence and reprint requests to Dr. Fonseca.
For proper growth and development to occur,
cleft repair of any sort ideally should be delayed
until after growth is complete. However, nutrition,
speech, swallowing, esthetics, and psychologic well-
being make the problem complex. Early soft tis-
sue repair of the cleft lip and palate is necessary
for the attainment of normal speech, swallowing,
and psychologic acceptance. Clifford reported the
greatest dissatisfaction: that on long-term follow-up,
patients with cleft palate were displeased with the
appearance of their teeth and with their speech. The
goal of all cleft palate repair procedures is to
achieve the best possible physiologic and psycho-
logic function with a minimum of disturbance to
growth and development.
In the 197Os, studies appeared suggesting that, if
bone graft repair of alveolar clefts was delayed until
the age of mixed dentition (about 8 to 14 years),
good function would result, and there would be
much less effect on growth and development.
Boyne and Sands reported the results of alveolar
cleft grafting on ten patients. Their recommended
operation time was between ages 9 and 11, before
the canine teeth had fully erupted. The procedure
involved grafting autogenous cancellous bone and
marrow to clefts in patients not requiring ortho-
gnathic surgery but in need of teeth in the newly
restored osseous alveolar ridge. The oronasal soft
tissue communication was closed during the proce-
dure. Canine teeth erupted into the grafted areas in
eight patients. A reported minor complication was
vestibular sulcus shortening, which could be cor-
rected later by vestibuloplasty.
Broude and Waite reported 33 cases in which
iliac crest bone was used to close alveolar defects.
A majority of their patients with cleft palate showed
0278-2391/82/l 100/0721 $01.00 @ American Association of Oral and Maxillofacial Surgeons
721
722
severe malocclusions, which required maxillary seg-
mental or total maxillary orthognathic surgery prior
to repair of the alveolar defect. In these cases the
alveolar graft was performed two to three months
later. These workers emphasized the importance
of a careful closure of the nasal mucosa for a suc-
cessful graft. A labial pedicle flap from the vestibule
was used to cover the bone graft.
Waite and Kerste@ stated that if the alveolar
ridge defect were left untreated, one or more of the
following features would be present:
1. Alveolar ridge displaced palatally on the cleft
side with frequent tooth malalignment.
2. Deficient bone support for teeth adjacent to
cleft.
3. Inadequate oral hygiene due to oronasal fistula
and malaligned teeth.
4. Maxillary segmental mobility and compro-
mised prosthetic appliances.
5. Affected speech from altered arch contour
and/or fistulae.
Epker and Wolfords found that when properly
timed and performed, alveolar grafting provides
relatively normal alveolar bone continuity, good
stabilization for mobilized or expanded maxillary
dento-osseous segments, and supporting bone for
adjacent teeth to erupt into or be orthodontically
moved into and can improve the periodontal health
and longevity of teeth adjacent to the cleft. They
list the basic goals for surgery as follows:
1, Stabilization of dento-osseous segments.
2. Improvement of alveolar continuity.
3. Prevention of tooth loss due to periodontal dis-
ease.
4. Provision of alar base support.
The preferred time for alveolar cleft grafting ac-
cording to Waite and Kerster? is between the ages
of 9 and 11, before the canine teeth have fully
erupted. Ideally, the canine tooth should be high in
the alveolus on the cleft side. Their surgical tech-
nique involved closing the mucosa of the nasal
floor, placing a cortical-particulate medullary iliac
crest graft, and closing with a pedicled mucosal or
mucoperiosteal flap. They observed that the pedi-
cled flap rarely foreshortened the vestibule.
The purpose of this study is to describe a tech-
nique for alveolar cleft grafting and to evaluate the
results obtained with this procedure.
Mat er i al s and Met hods
The 30 patients selected for this study had under-
gone a grafting procedure of either unilateral or
bilateral alveolar cleft at the University of Iowa
Hospitals and Clinics from 1977 to 1980. Those pa-
tients no longer being followed up routinely were
telephoned and an interview and examination were
ALVEOLAR CLEFT GRAFTING
arranged. Routine follow-up appointments were used
for subjects more recently operated on. Several of
the appointments were made in conjunction with
orthodontic follow-up.
At the time of the recall examination, the length
of time since the graft, age at the time of surgery,
and present age of the patient were noted. An
occlusal radiograph was taken, and if malaligned
teeth obscured the graft site, periapical radiographs
were also taken. All subjects were examined and
radiographs interpreted by the same person (JBT).
Sixteen female and 14 male subjects were exam-
ined at an average of 17.1 months after surgery
(range 2 to 26 months). The success of the grafts
was evaluated in terms of the following features:
presence of oronasal fistulae, eruption of previously
unerupted teeth into graft, soft and hard tissue peri-
odontal status, and radiographic evidence of bone
fill in the previous cleft defect resulting in alveolar
segmental stabilization. The average age at the time
of surgery was 13.2 years, with a range of 7 to 26
years.
PREOPERATIVE INFORMATION
The chief complaint or reason for surgery was
recorded for each patient. The information came
from either the patient, the parent (s), or the admis-
sion history and physical examination. The nature
of the alveolar cleft (unilateral or bilateral) as well
as any associated syndrome was recorded. The
source of the bone graft material was discovered
from the admission history and physical examina-
tion. Information regarding the presence or absence
of an oronasal tistula was obtained from preopera-
tive photographs and the history and physical ex-
amination. Preoperative radiographs were used to
determine whether unerupted teeth were present
prior to the graft. Preoperative photographs and the
history and physical examination established whether
the patient was under orthodontic treatment before
surgery.
INTR.~~PERATI~E INFORMATION
The type of procedure performed and, in the case
of bilateral clefts, whether both clefts were treated
was recorded. Other factors tecorded were splint
placement, estimated blood loss, medications, and
immediate complications. Blood loss estimations
were made for both the cleft and iliac crest proce-
dures.
POSTOPERATIVE INFORMATION
The postoperative evaluation involved checking
for the presence of an oronasal fistula, a periodontal
TROXELL ET AL
723
examination of the maxillary teeth, and a radio-
graphic survey of bone bridging and tooth movement
into the graft site. A periodontal probe was used to
determine sulcular depth at six points around each
of the maxillary teeth. The zone of attached gingiva
was measured at the cleft site in the region of the
four-cornered suture placement. The presence or
absence of an oronasal fistula was noted clinically
and recorded with photographs. Tooth movement
was examined clinically and radiographically by
comparisons between preoperative and postopera-
tive films. Evidence of bone bridging was also eval-
uated radiographically.
TECHNIQUE FOR REPAIRING UNILATERAL CLEFTS
After general anesthesia was given in the operating
room, the patient was prepared and draped for si-
multaneous procurement of the iliac crest graft and
the alveolar cleft procedure. Either an oral or a
nasal endotracheal tube was used. An oral anode
tube was used most frequently because it allowed
complete access to the maxilla, nasal floor, and
upper lip and would not kink when head positions
were changed. Also, an oral tube would not disturb
a pharyngeal flap.
The iliac crest procedure was performed as de-
scribed in the literature.lO~li No cortical bone was
taken: the graft consisted of cancellous bone and
marrow. Approximately 20 cc was obtained, the
amount varying with the cleft size. With patients
treated before October 1979, the graft was stored in
the patients own blood until placement. After that
time, it was kept in normal saline, as recommended
by Marx. I2
After placement of a throat pack, the unilateral
cleft (Fig. 1, rtbove) was examined. Two percent
lidocaine with 1: 100,000 epinephrine was infiltrated
along the cleft for hemostasis and ease in dissection.
The anesthetic needle was used to probe the bony
margins of the cleft both palatally and labially. After
the width of the bony defect had been determined, a
pericoronal incision was made in the sulcus from
either the first or the second molar to the corre-
sponding tooth on the opposite side of the arch. An
incision was then made along the palatal aspect of
the cleft through mucosa to bone. The incision was
beveled to preserve palatal mucosa and to avoid the
need for inversion of a large amount of tissue into
the floor of the nose. The interdental papillae of the
teeth adjacent to the cleft were reflected to improve
visualization. An incision over the crest of the ridge
was made anterior and posterior to the cleft. Careful
reflection and handling of this tissue was important
because it was used in the four-cornered closure.
Often the anterior and posterior extent of the bony
cleft was not clearly demarcated. and the superior
FIGURE 1. Above, Preoperative appearance of unilateral al-
veolar cleft. Center, Flap design for double layered closure of
defect and buccal and palatal advancement prior to grafting.
Brlau~, Buccal and palatal advancement flaps sutured in place
with four-corner approximation.
extent of the incision was therefore tapered into the
submucosal tissue. After adequate reflection of soft
tissue, the margins of the nasal mucosa were approxi-
mated with 4-O Vicryl suture on a P-2 cutting
needle. A careful check of the closure in the region
of the oronasal fistula was done because an epi-
thelium-lined tract would have jeopardized the
_
* Ethicon: polyglactin 910 braided suture.
724
ALVEOLARCLEFTGRAFTING
FIGURE 2. Above, Preoperative appearance of bilateral al-
veolar cleft defect with outline of palatal and labiobuccal inci-
sions for the advancement flaps. Center. Flap design for
double-layered closure of defect and buccal and palatal ad-
vancement flaps prior to grafting. Below, Placement of bone
chips and four-cornered closure of flaps.
closure. The nasal soft tissues were repositioned
superiorly to form the floor of the nose (Fig. 1,
center).
Vertical releasing incisions were made on the
palatal and labial aspects in the molar regions. Full
mucoperiosteal flaps were then reflected on the
palatal and labial aspects of the alveolus. Relaxation
of the labial flaps was gained by periosteal releas-
ing incisions. Generally, a tension-free closure was
obtained by advancement of the papillae one tooth
toward the midline. The palatal closure was begun
with 4-O Supramidt suture. The bone graft was
packed into the prepared site. Closure was com-
pleted with a four-comer suture over the graft site
and multiple simple interrupted sutures to approxi-
mate the remainder of the incision (Fig. 1, below). A
prefabricated acrylic splint was ligated to a tooth on
each side of the arch with 0.018 inch wire. Patients
were routinely given preoperative and postopera-
tive antibiotics and steroids. Decongestants were
given postoperatively as needed. A humidifier at the
bedside helped keep the patients nasal mucosa
moist. The splint and sutures were removed after 14
days.
TECHNIQUE FOR REPAIRING BILATERAL CLEFTS
The bilateral alveolar cleft graft procedure was
similar to the unilateral repair. Both clefts were
grafted in one stage. The incisions and flaps were
developed in the same fashion except in the pre-
maxillary region, where a mucoperiosteal tissue
cuff sufficient for closure was reflected from the
posterior aspect of the premaxilla (Fig. 2, above).
The nasal floor tissue was reflected and closed
bilaterally (Fig. 2, center). Periosteal and vertical
releasing incisions were important in the bilateral
procedures because the premaxillary tissue cuff did
not advance easily. After the graft was placed, the
oral closure was begun (Fig. 2, below). Two four-
comer sutures were tied, and the remainder of the
wound was closed with simple interrupted sutures.
Resul t s
PREOPERATIVE PERIOD
The presence of an oronasal fistula was the most
frequent complaint prior to surgery. Most patients
had been referred by their orthodontists; three were
referred by prosthodontists.
Nine patients (30%) had unilateral right-sided
alveolar clefts, and 17 (57%) had left-sided defects.
Four clefts (13%) were bilateral, and 28 patients
(93%) had preoperative oronasal fistulae. In 19 pa-
tients (63%) an unerupted tooth adjacent to the cleft
site was visible in the radiograph. Twenty-two
(73%) of the 30 patients were receiving orthodontic
care at the time of surgery.
i S. Jackson. Inc.: polyamide polytilament suture.
TROXELL ET AL
INTRAOPERATIVE PERIOD
The average estimated blood loss was 355 ml
(range, 75-1200 ml). The blood loss estimate was
for both the iliac crest procedure and the alveolar
cleft grafting. In addition, one patient underwent
bilateral intraoral vertical ramus osteotomies of the
mandible. The average length of hospitalization was
4.6 days, which included one-half day for admis-
sion, one-half day for discharge, one day for sur-
gery, and 2.6 days for recovery time. All patients
received prophylactic antibiotics. Penicillin was the
drug of choice except for patients with a history of
allergy to penicillin. Dexamethasone was the anti-
inflammatory agent administered. Decongestants
were ordered as needed. No immediate postopera-
tive complications were observed.
POSTOPERATIVE PERIOD
The average size of the zone of attached gingival
tissue in the region of the four-cornered closure was
4.3 mm (range, O-10 mm). Postoperative tistulae
developed in two patients, one with a unilateral cleft
and the other with a bilateral cleft. Two patients had
dehiscence of the wounds; one admitted to nose-
blowing postoperatively, and the other was a juve-
nile diabetic with a bilateral cleft. In 18 of 19 pa-
tients (95%) with an unerupted tooth adjacent to
the cleft, there was tooth movement into the graft
site. In one case it was too early to determine
whether tooth movement would occur. No peri-
odontal sulcular depths greater than 4 mm were
measured: the average was 3 mm. Twenty-nine of
the 30 patients (97%) showed radiographic evidence
of bone bridging across the graft site.
Di sc ussi on
The need for greater stability of the alveolar seg-
ments is a recognized indication for bone grafting.
Twenty-nine patients showed bone bridging and in-
creased alveolar stability after surgery. In 28 pa-
tients, closure of an oronasal fistula was achieved.
As Broude and Waite7 and Epstein et all3 have em-
phasized, development and careful closure of the
flaps that become the nasal floor is essential for
success.
Grafting also favors tooth eruption. Seventeen of
18 patients with impacted canine teeth showed
725
either clinical or radiographic evidence of tooth mi-
gration into the bone graft. This compares favorably
with the results obtained by Waite and Kersten,#
who reported that 75% of unerupted canine teeth
showed eruption into the bone graft.
Although various pedicle flap closures have been
described in the literature, these authors have not
seen the technique of bilateral buccal flap advance-
ments described previously. An advantage of the
technique is that a zone of attached gingival tissue is
placed over the cleft site to achieve a more natural
alveolar ridge. The average of more than 4 mm of
attached tissue provides acceptable periodontal
health for the adjacent teeth. The one patient in
whom tissue attachment did not occur later under-
went a successful free gingival graft with the use of
paptal mucosa. As noted by Waite and Kerstenx
the sulcular depth was decreased in some cases.
This can be corrected by secondary vestibuloplasty.
Ref er enc es
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