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CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART TWO

J Oral Maxillofac Surg 61:1082-1090, 2003

Secondary Osteoplasty of the Alveolar Cleft Defect


Bruce B. Horswell, MD, DDS, MS,* and James M. Henderson, MD, DDS
Reconstruction of the alveolar cleft defect (ACD) has been a controversial subject since the rst reported bone graft series in 1955.1 Since that time, there have been hundreds of published reports that have addressed issues of perioperative orthopedics, timing of osteoplasty (bone grafting), types of grafts, simultaneous procedures, etc.2-4 This report focuses primarily on the controversy surrounding timing of ACD repair with brief comments on types of bone grafts. It is assumed that the readership is acquainted with the issues at hand, such as craniofacial development, orofacial cleft anatomy, bone repair physiology, and detailed operative techniques. The senior author (B.B.H.) adheres to early secondary osteoplasty (bone repair of the ACD, roughly 5 to 8 years). This report takes the position that this is optimal cleft management and substantiates such by the literature. But, rst, a word on primary osteoplasty, or bone graft repair before 2 years of age. The primary osteoplasty bandwagon, small as it is, has been circling the globe, visiting various cleft management centers for nearly 50 years. It enjoyed some popularity during the early years of ACD osseous reconstruction, but in the decades to follow (1960s to 1970s), the rst dropouts began to sound the alarm of retruded maxillas, dreadful crossbites, and poor alveolar morphology with unerupted or unsupported teeth.5-13 The primary enthusiast for infant osteoplasty in the United States has been the Northwestern University Cleft Team in Chicago.14 They were joined by the
Received from Charleston Area Medical Center, Charleston, WV. *Medical Director, First Appalachian Craniofacial Deformities Center. Consultant Surgeon, Facial Surgery Center. Address correspondence and reprint requests to Dr Horswell: First Appalachian Craniofacial Deformities Center, Charleston Area Medical Center, 830 Pennsylvania, Charleston, WV 25302; e-mail: bruce. horswell@camc.org
2003 American Association of Oral and Maxillofacial Surgeons

Indianapolis group15 in the early 1980s. Primary osteoplasty, as described by these 2 groups, generally is performed after infant orthopedics and primary lip repair and before palatoplasty. A small rib graft is split and introduced through small mucoperiosteal tunnels to be passively placed across the labial aspect of the alveolus. Importantly, no bone is placed into the defect and no dissection is carried into the premaxillaryvomerine suture.16 In Europe, most centers have opted for secondary or delayed bone grafting after a vigorous 20-year experiment with primary osteoplasty. Indeed, some of the most vocal opponents of primary osteoplasty were those who earlier had embraced infant bone grafting.17 However, the Stockholm group still performs primary osteoplasty.18 Secondary osteoplasty of the ACD grew out of the early disappointments of primary bone repair.19-22 However, it was Boyne and coworkers23,24 who conrmed that bone grafting of the ACD during the mixed dentition stage was safe, predictable, and preferable. Reports from many different centers soon followed that supported their ndings.25-32 The secondary alveolar bone graft procedure has been established as the gold standard for ACD reconstruction and has provided a foundational support in contemporary cleft management.30-34 To follow is a treatise regarding this foundation, but the reader should remember that an open mind is important when reviewing modern surgical proceduresthe technology and research may some day direct us to alter many of our current approaches to congenital defects, especially the orofacial cleft.

Secondary Osteoplasty
HISTORY

0278-2391/03/6109-0018$30.00/0 doi:10.1016/S0278-2391(03)00322-7

The rst reported bone graft to the cleft maxilla is attributed to Lexer (1908)35 nearly a century ago. For 50 years, bone grafting was sporadic and performed without clear objectives. With the establishment of cleft centers, principally in the United States and Europe, goals for rehabilitation of the cleft patient were developed and protocols for management were

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devised. Because the cleft maxilla represented the challenge to successful rehabilitation of orofacial function, it made intuitive sense to surgeons to unite and stabilize the maxilla with an autogenous bone graft, once the lip and palate had been repaired.19 Eventually, several objectives for cleft reconstruction crystallized, summarized here by Witsenburg2:

A united, symmetric maxilla Closure of the oronasal stula Bony support for the dentition (preeruptive and posteruptive) A morphologically and physiologically responsive alveolus Osseous support for the nasal alar base and lip
FIGURE 2. Radiograph taken in a 14-year-old showing poor bone support for the canine and central incisor. Bone grafting should have been performed in the mixed dentition to provide optimal support and alveolar height.

These goals of alveolar cleft management should be the essential factors in selecting techniques and timing for treatment. Proposals for treatment should achieve these objectives in a timely manner without interfering with dentofacial development.32,34,36 With these ideals in mind, many centers began to place the bone graft during the mixed dentition stage before eruption of the permanent canine.21,27,36-39 Some groups advocated earlier grafting (4 to 6 years) to provide a bone matrix for the erupting incisors, if there appeared to be insufcient support40,41 (Fig 1). The timing of graft placement is based more on dental development than on chronologic age, and the mixed dentition stage is favored for several reasons: Transverse growth of the maxilla is nearly complete; therefore, there is little additional adverse effect on development.17,34 Perioperative orthopedics can easily and predictably align the arches and prepare the defect for graft placement.29 Provision of osseous support for erupting teeth enhances overall health and stability.28,37,42

Later grafting (after canine eruption) is associated with less graft take, more remodeling and eventually less alveolar height39,43(Fig 2).
BENEFITS OF SECONDARY OSTEOPLASTY

Maxillary Arch Continuity Uniting the cleft maxilla into one continuous arch is a universal goal in cleft management.44,45 Even for those centers that principally rely on gingivoperiosteoplasty (a word on this later) to produce bone, rather than bone grafting, restoring maxillary continuity is a key objective.46-52 Placement of an autogenous bone graft into a well-prepared alveolar defect site and covered with adequate and healthy mucogingival aps will result in a united and functional maxilla. Deferring such to the mixed dentition stage when maxillary transverse growth is nearly complete will minimize the hazards to growth stimuli.3,17,30,32 Bone Support for Dentition The advantage of secondary osteoplasty offers a 2-fold considerationit provides a bone matrix for eruption of teeth and support for the permanent teeth once orthodontics is completed.26,29,33,37,45,53,54 When primary and secondary osteoplasty were compared on this issue, there appeared to be less favorable bone in primary sites to accommodate erupting teeth or the grafted bone (primarily rib) seemed to inhibit eruption in many cases.7-13 Many centers prepare the ACD for bone grafting with presurgical orthopedics to optimally create a defect that can be closed in the nasal oor, receive a bone graft that is covered with tension-free, wellvascularized gingival aps, and position teeth into favorable alveolar bone (Fig 3). Presurgical orthope-

FIGURE 1. Radiograph showing insufcient bone support for the lateral incisor. The alveolar cleft defect should have been grafted before its eruption (early secondary osteoplasty).

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FIGURE 3. Cleft defect lled with cancellous bone, condensed against repaired nasal oor.

dics should be designed to approximate very wide unilateral cleft defects, stabilize the premaxilla in bilateral clefts, and attempt to vertically align the alveolar processes.29,31,32,34 When appropriately prepared, the ACD can be easily grafted, and, in a majority (greater than 90%) of the cases, one can expect the teeth to erupt properly, occupy a stable position in the arch, and have healthy periodontal support53-55 (Fig 4). Occasionally, some canines need to be surgically exposed and orthodontically guided into an ideal arch relationship.28,37,39,41,55,56 Oronasal Fistula Elimination Fistulas vary in size and consequence for the cleft patient. Generally, oronasal stulas present several challenges in cleft management: anterior nasal air escape during speech,57,58 periodontal compromise,59 unpleasantness to the patient,25,29 nasal sill and alar base deciency,32,47,60-62 and, premaxillary instability in bilateral clefts.55,63 Primary osteoplasty has been cited as a procedure of choice to eliminate stulas14,64; however, little has been published to support this statement. Indeed, the early enthusiasts of primary bone grafting found that, although a bony bridge was created across the defect, this did not always translate into stula closure and adequate osseous continuity across the nasal oor.5-13,65 Secondary osteoplasty, on the other hand, has resulted in closure of the defect proper and eradication of oronasal stulas in the majority of patients. Graft failure and subsequent restulization are attributed to poor local tissue, wide ACDs, unstable premaxillae, older patients, and poor surgical technique.34,39,43,65-67 Ideal Alveolar Morphology A distinct advantage of secondary osteoplasty is the establishment of a sound and well-contoured alveolar process, which will provide support for teeth and

periodontium. In most instances, this ideal ridge form is attained and maintained after nal stage orthodontics. One study using immediate and 1-year postsurgical CT scans conrmed that signicant bone volume remained after secondary osteoplasty.68 After graft incorporation and osseous healing, it is important to bring the reconstructed alveolar process under functional load by either nal orthodontic closure or prosthetic replacement of missing teeth69-71 (Figs 4, 5). If insufcient bone is present, a smaller graft with membrane coverage will allow for optimal implant placement. Distraction of the reconstructed alveolus also represents a possible avenue for increasing bulk and providing for subsequent implant placement.71 In regard to the promises of infant bone grafting providing a favorable osseous milieu for erupting teeth, Epstein et al10 stated, Our observations agree with those of Pickerell and associates; we have never seen this occur. More recently, the long-term ndings of Keese and Schmelzle72 showed decreased vertical height in the anterior maxilla of patients who had

FIGURE 4. Radiographs of alveolar cleft defect without preoperative orthodontic preparation. There is good bony ll and apparent osseous support for the teeth; however, postoperative arch expansion may result in some loss of alveolar height.

HORSWELL AND HENDERSON

1085 studies that were not optimally designed, yet the collective observation from so many prompted a nearhalt to bone grafting until growth was almost complete.2,12 Pruzansky, a pioneer and pillar in contemporary cleft management, questioned those who performed infant orthopedics and periosteoplasty and strongly cautioned against early bone grafting with his dissent in 196478: Their battle cry is a cabalistic mumbo-jumbo invoking the mystique of embryology and growth and development. His concerns were echoed by McCarthy et al79: Primary bone grafts do not grow as originally postulated but instead hinder growth with a signicant limitation of maxillary development. . . . It is difcult to disregard such warnings. A state-of-the-art review by Kuijpers-Jagtman and Long32 on maxillofacial growth in cleft treatment indicated that patients who had undergone secondary osteoplasty had more favorable nasomaxillary prole than those who had had primary osteoplasty procedures. The latter group tended to have atter proles, although acceptable dental relationships were maintained via a general backward-downward rotation of the maxillomandibular complex. This nding was also observed by Smahel and coworkers,49,80,81 when they compared facial growth in patients repaired with primary periosteoplasty (no bone), primary osteoplasty (rib graft), and nonclefted children. They determined that the least favorable facial prole was in the primary bone grafted group. Exhaustive reviews by Koberg,12 Witsenburg,2 Semb and Shaw,30 Kuijpers-Jagtman and Long32 and others point to the high success of secondary osteoplasty in achieving the previously stated goals of cleft defect management, including acceptable facial development. The need for orthognathic surgery to correct mid-face retrusion and cross-bite varies in many of these reports from 10% to 50%, yet, as Posnick82 points out, what one center may accept for nal skeletofacial relationships may differ from what another center accepts, thus skewing the need and rate of corrective jaw surgeryperception may direct treatment. Also, there will always be those severe clefts that may have a poorer result (a atter mid-face) despite good procedures performed at the right time by a technically sound surgeon. Surgery will inict some harm to tissue that may not always be overcome.

FIGURE 5. Postgraft alveolar cleft defect with good alveolar morphology and covered with healthy mucoperiosteum. This region should be functionally restored within 1 year to maintain alveolar bulk and height.

undergone primary osteoplasty with rib graft. They also reported that 70% of patients had less than 50% ideal alveolar bone height. Nasal Support Alar bone support is an important objective in cleft reconstruction.2,17,27,60,73,74 After functional repair of the lip and nose (primary cheilorhinoplasty), one can expect some osseous response in the alar base and anterior maxilla.47,61 Bony appositional growth will take place when proper musculoaponeurotic mechanisms are in place, although this is diminished in part in the region of the cleft defect. When this appositional growth has slowed in the mixed dentition, further reconstructive surgery may be undertaken at the time of ACD bone graft placement to augment what has not been intrinsically obtained.55,75 Kokkinos et al76 place hypophyseal cartilage around the piriform rim to obtain a balanced and well-projected alar base. They believe that this is more permanent because it is less pone to remodeling. Simultaneous alveolar bone grafting and limited nasal surgery may also be carried out during the later childhood years. Autogenous bone can be placed in the ACD, with a small stent placed at the region of the anterior nasal spine to increase nasal projection.75 One should consider these procedures as establishing proper skeletal foundation for nal soft tissue revisions.77 Facial Growth Little in cleft management has stirred the pot of controversy more than the issue of bone grafting (primary versus secondary versus none at all) and its possible deleterious effect on maxillofacial development. From the rst reports of poor growth, more than 40 years ago, the debate has continued to the present day. The rst centers to report poor maxillary growth after primary osteoplasty perhaps did so based on

Bone Grafts Sources


As intense as the issue of timing of osseous repair in cleft management has been the search for the ideal graft material. Many sources, both autogenous and alloplasts, have been studied, compared, highly proled, abandoned, and so on. A review of autogenous

1086 sources of bone grafts for secondary osteoplasty will serve our purposes in this report. First, a word on boneless-bone grafting as rst advanced by Skoog46 and modied by others. It was theorized that if healthy mucoperiosteum was closed over the ACD during primary lip repair, favorable osteogenic conditions would allow osseous bridging across the defect. This procedure has been termed primary gingivoperiosteoplasty. Alveolar defects thus repaired reportedly lled with sufcient bone to support erupting primary teeth. The percentage of children who have shown some osseous repair of the primary ACD after gingivoperiosteoplasty has been variably reported from 50% to 100%.48-50,83,84 In some of these centers, therefore, bone grafting is not a routine procedure in many of the children. The question then becomes, are some infants who have undergone primary osteoplasty receiving unnecessary grafts (more surgery)? Those who perform primary gingivoperiosteoplasty would probably indicate such. On the other hand, some centers, like the Oslo group,27,30 would argue that all alveolar defects will remain decient in osseous contour and bulk, thus necessitating eventual bone graft placement.
ILIAC CREST

SECONDARY OSTEOPLASTY

does not offer sufcient advantage over iliac bone for ACD reconstruction to warrant its recommendation.
TIBIA

Tibia has been favored as a source for some surgeons. Ease of harvest, less bleeding, rapid return to ambulation, and sufcient cancellous marrow depot have been cited as advantages.56,66,86-88 Still, the possibility of damage to the epiphysis is not to be taken lightly, as the consequences of growth plate damage in a growing child is serious.88
CALVARIUM

Calvarial bone offers the advantages of the same operative eld, hidden scar in hairline, and little postoperative discomfort.89 This source of autogenous bone was popularized by Zins and Whitaker90 when they noted its high potential for craniofacial reconstruction due to its intramembranous nature. Although calvarial bone has been found to be well incorporated into the ACD,91,92 its limited cancellous portion has limited its applicability.75 Also, increased operating time due to inability to simultaneously prepare the ACD and harvest bone is a disadvantage.
MANDIBLE

Most bone grafts to the ACD have been particulate marrow harvested from the anterior iliac crest and represent the standard graft to which other materials are compared. Since Boyne and Sands23 rst reported on their series of successful secondary osteoplasties, many other centers have followed with similar success.21,22,25-34,39,41,44,53-56 Iliac crest is favored due to the usually generous amount of cancellous marrow that can be harvested. Iliac crest grafts can be harvested quickly and simultaneously while the recipient site is being prepared. Children usually recover quickly and ambulate well within a week of surgery. Particulate cancellous-marrow grafts are well incorporated into the ACD and contribute to osteogenesis at the site of repair through survival of osteocytes and later induction of osteoblastic activity.
RIB

Finally, mandible chin bone has been used as a bone graft in ACD repair.93 Obviously, same site and ease of harvestation would make it very suitable as a graft choice. The primary champions of this source for ACD repair have been the Nijmegen94 and Aarhus95 cleft centers. In fact, Freihofer et al94 reported the best results with chin bone. Its major drawback is a limited amount of available cancellous stock; therefore, its application is more suitable for smaller or narrow defects.

New Graft Materials


Resorbable and nonresorbable bone substitutes have been extensively studied for their utility in orofacial repair. Due to unpredictability in resorption or in the amount of bone formed, these materials have been limited to use in the late secondary osteoplasty or adult patient with minor alveolar deciency. Recently, there have been several studies that have shown that bone defects can be reliably repaired with recombinant human bone morphogenetic protein (rhBMP-2).96 These proteins have been shown to regenerate bone in long bone, vertebral, calvarial, and mandibular defects.97,98 The application of rhBMP-2 in created alveolar clefts in a beagle model has resulted in a bone regenerate that allows normal tooth eruption.99 With appropriate dosing regimens (yet to be determined), this graft material may replace au-

Rib probably has been the next most often used autograft for ACD repair. Rib and calvarium are the only practical sources of autogenous bone in primary osteoplasty. Several reports have commented on the inadequacy of rib as a graft material for alveolar repair due to incomplete incorporation or turnover into alveolar bone, inadequate bone stock for tooth eruption, and little support for the nasal base.7-13,22 Scar, possibility of pneumothorax, and postoperative pain (sometimes lasting several weeks) are cited disadvantages.85 By the mixed-dentition stage, rib probably

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1087 and, more recently, resorbable lm (as used in abdominal surgery to prevent adhesions). In large defects with several aps and incision lines, the author has placed tissue glue across the incisions to effect a better seal. Although no research has been conducted to conrm the usefulness of these adjunctive materials, the anecdotal feeling is that they have a place in cleft osteoplasty. Probably the most challenging of all ACD entities to treat are those in which severe bone loss has taken place, and the native alveolar bone height is less than 50% on the incisor or canine roots, or in retreatment defects where a graft has already failed. It is very difcult to maintain existing bone height, let alone increase height or bulk, when a compromised dental and periodontal condition is present, which is often the case in retreatment. Again, we have found it benecial to bring all hands on deck, vis-a-vis ` achieve optimal oral health, frequent recall of the patient and vigilance in the perioperative period, and good nutrition. We have often been amazed at how quickly the oral soft tissues will slough or dehisce when a child is not taking in good postoperative

togenous bone as the ideal material in the very near future.

Pearls in Secondary Osteoplasty


The senior author (B.B.H.) mentioned earlier that he prefers early osteoplasty, that is, grafting between 5 and 8 years of age. This is because bony support for the central incisors is secured at this time and ultimate alveolar height is thought to be achieved and maintained. But success depends on many factors. It is paramount to have a well-prepared recipient site for the intended bone graft. This means the following should be in place:

Sound dentition free of disease Healthy mucogingiva Demonstrated ability of the patient (or parents) to maintain satisfactory oral hygiene Control of nasal-sinus discharge through cleansing nasal sprays, decongestants, antihistamines, and aerosolized topical steroids, as indicated

We believe the last factor is one frequently overlooked. Many cleft children suffer from chronic otitis, sinusitis, and upper respiratory infections with constant nasal obstruction and mucus discharge that accompanies these problems. To attempt a bone graft repair in the midst of these nasal conditions is to invite mucosal dehiscence and loss of the graft material. Therefore, at least 2 months before anticipated bone graft, these conditions and allergies should be brought under control as much as possible. Communication with primary care providers and indicated specialists is very important. If nasal obstruction or severe rhinorrhea persists, then radiographic and nasopharyngoscopic examination is warranted. Ofce nasopharyngoscopic examination will allow for careful evaluation of nasal stulae, mucosal health, adverse septal deviation, turbinate hypertrophy, polyp formation, and sinus mucous discharge. Adverse conditions, such as turbinate hypertrophy or septal deviation, are planned for simultaneous correction. This may also create access for nasal oor reconstruction and ease of graft placement. In the last 6 years, the senior author has used a variety of materials or membrane barriers to seal the bone graft from incision lines, to encourage endosteal healing, and to discourage osteolytic mechanisms. Much in the same way as barriers have been used in alveolar height augmentation for implant placement or periodontal defect repair, these materials can facilitate osseous healing and maintenance of the bone graft in cleft defects. These materials have included Gore-Tex (W.L. Gore & Associates, Inc, Flagstaff, AZ), resorbable mesh, connective tissue grafts (palatal),

FIGURE 6. A child, who happens to have a cleft, and her doctor . . . mostly a happy time together.

1088 nutrition. Liquid supplements and multivitamin preparations may be indicated. A child who has shown little interest in oral hygiene and where family supports are lacking will often have a compromised result. A cleft defect with less than 50% bone coverage on neighboring teeth is a challenge. Options are to manage the defect as a periodontal defect with vigorous preoperative root preparation and using membranes over the bone graft. The goal is to maintain alveolar bone height through nal stage orthodontics or restorative treatment. If a defect is not planned for orthodontic closure, then loading the grafted defect is important; plans should be made for the placement of an endosteal implant. Contemporary cleft defect reconstruction uses autogenous bone harvested from a variety of sites, principally the iliac crest, and placed during the mixed dentition stage, before eruption of either the incisors (early secondary osteoplasty) or canine (mid secondary osteoplasty). This review of secondary osteoplasty for ACD repair has addressed the indications for and benets of autogenous bone repair. The literature suggests that bone grafts placed at this time are well incorporated, become a functional and responsive alveolus, and provide nasal and maxillary support for overlying soft tissue. The future of cleft defect reconstruction will lie in the area of developing graft substitutes that contain BMP and can be easily and safely introduced during primary cheilorhinoplasty. In summary, it is hoped that the above observations and recommendations for the treatment of ACDs will be helpful. Children with clefts can often be the most challenging to treat; however, as many have discovered, she or he can also be one of the more satisfying and rewarding children to treat (Fig 6).

SECONDARY OSTEOPLASTY
8. Robertson NRE, Jolleys A: Effects of early bone grafting in complete clefts of the lip and palate. Plast Reconstr Srug 42: 414, 1968 9. Robinson F, Wood B: Primary bone grafting in the treatment of cleft lip and palate with special reference to alveolar collapse. Br J Plast Surg 22:336, 1969 10. Epstein LJ, Davis WB, Thompson LW: Delayed bone grafting in cleft palate patients. Plast Reconstr Surg 46:363, 1970 11. Rehrmann A, Koberg WR, Koch H: Long term postoperative results of primary and secondary bone grafting in complete clefts of lip and palate. Cleft Palate J 7:206, 1970 12. Koberg WR: Present view on bone grafting in cleft palate (a review). J Maxillofac Surg 1:185, 1973 13. Pfeifer G: Der EinuB der primaren osteoplastik be: Lippen-, Kiefer-, Gaumenspalten auf das Oberkieferwachstum, in Pfeifer G (ed): Lippen-Kiefer-Gaumen-Spalten. Stuttgart, Germany, Thieme, 1982, p 97 14. Rosenstein S, Monroe CW, Kernahan DA, et al: The case for early bone grafting in cleft lip and cleft palate patients. Plast Reconstr Surg 70:297, 1982 15. Nelson CL: Primary alveolar cleft bone grafting. Oral Maxillofac Surg Clin North Am 3:599, 1991 16. Sadove AM, Eppley BL: Timing of alveolar bone grafting: A surgeons viewpoint. Problems Plast Reconstr Surg 2:39, 1992 17. Ross RB: Treatment variables affecting facial growth in complete unilateral cleft lip and palatepart 3: Alveolus repair and bone grafting. Cleft Palate J 24:33, 1987 18. Nylen B: Surgery of the alveolar cleft. Plast Reconstr Surg 37:42, 1966 19. Axhausen G: Technik und Ergebnisse der Spaltplastiken. Munchen, Germany, Karl Hauser Verlag, 1952 20. Nordin KE, Johanson B: Freie knochen transplantationen bei Defekten im Alveolarkamm nach Kieferorthopadischer Einstellung der Maxilla bei Lippen-Kiefer-Gaumen-Spalten. Fortsch. Kiefer-Gesichtschir, vol 1. Stuttgart, Germany, Thieme, 1955, p 168 21. Abyholm F, Bergland O, Semb G: Secondary bone grafting of alveolar clefts. Scand J Plast Reconstr Surg 15:127, 1981 22. Pfeifer G: Early treatment of cleft lip and palate, in Proceedings of the Third International Symposium on Craniofacial Anomalies. Zurich, Switzerland/Stuttgart, Germany, Huber, 1984, p 110 23. Boyne PJ, Sands NR: Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 30:87, 1972 24. Boyne PJ: Use of marrow cancellous bone grafts in maxillary alveolar and palatal clefts. J Dent Res 53:821, 1974 25. Enemark H, Krantz-Simonsen E, Schramim JE: Secondary bone grafting in unilateral cleft lip palate patients: Indications and treatment procedure. Int J Oral Surg 14:2, 1985 26. Vig KWL, Turvey TA: Orthodonticsurgical interaction in the management of cleft lip and palate. Clin Plast Surg 12:735, 1985 27. Bergland O, Semb G, Abyholm FE: Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J 23:175, 1986 28. Lilja J, Moller M, Friede H, et al: Bone grafting at the stage of mixed dentition in cleft lip and palate patients. Scand J Plast Reconstr Hand Surg 21:73, 1987 29. Semb G, Bergland O: Long-term results of a rehabilitation procedure combining orthodontics and secondary bone grafting of alveolar clefts: bilateral complete clefts of the lip/alveolus/ palate, in Proceedings of the Fourth Hamburg International Symposium on Craniofacial Anomalies and Clefts of Lip, Alveolus, and Palate, 1987. Stuttgart, Germany, Thieme, 1991, pp 355-371 30. Semb G, Shaw WC: Facial growth in orofacial clefting disorders, in Turvey TA, Vig KWL, Fonseca RJ (eds): Facial Clefts and Craniosynostosis. Principles and Management. Philadelphia, PA, Saunders, 1996, pp 28-56 31. Vig KWL: Alveolar bone grafts: The surgical-orthodontic management of the cleft maxilla. Ann Acad Med Sing 28:721, 1999 32. Kuijpers-Jagtman AM, Long RE: The inuence of surgery and orthopedic treatment on maxillofacial growth and maxillary

References
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