ALVEOLAR BONE GRAFTING Alveolus Means Trough (Latin Word); Trough Containing Tooth Buds.

Various Forms of Cleft Alveolus

Cleft between laterals & canine ( ost co Tessier classification! "o.# (Tessiers$ %&'() Between centrals Tessier "o.* cleft More distall+ in the

on)

Cleft between centrals& Laterals Tessier "o.) cleft a,illar+ arch Tessier "o.-& "o.'

.istor+

/n %&*% 0 1on 2iselberg! 3sed 4edicled fla4 (bone of little finger) to fill alveolar cleft. /n %&*5 0 Le,ur! 6ree bone graft in cleft %&%# 0 7rachter! /st successful bone graft using tibial bone and 4eriosteu .

%&)% 0 1eau! Classification of cleft & atte 4ted tibial bone graft in alveolar cleft. 6ailed. %&-* 0 8ch id! 8uccessful AB9 using iliac bone graft 1950 !"mi#! 8uccessful AB9 using iliac bone graft

1955 $o"a%so% & Nor#i%' :ri ar+ AB9 using tibial bone in a stage 4rocedure li4$ 4alate$ alveolus 0 closure b+ % +r. of age. 19(0 !"u!"ar#t & )feifer' :ri ar+ AB9 using rib graft at the ti e of li4 closure. 19(*)ru+a%s,-' Bone grafting should be dela+ed until after eru4tion of 4er anent dentition 19(.$olle-' 7etri ental effects of earl+ bone graft on 19/0Bo-%e& a%#s' :rotocol for secondar+ AB9 19.12olfe et al' 6avourable result with calvarial bone 19./Ni3ue&Fo%se!a' AB9 with allogenic bone 7evelo4 ental Anato + of Alveolar Bone :re a,illa is a se4arate s;eletal unit (Moss ) /t develo4s fro edian nasal 4rocess (at Canine region) 6usion of 4re a,illa with a,illa 8tarts 5th wee; in utero a,illar+ growth

At Birt"

:re a,illa re ains se4arate fro Closure of suture starts fro of age 8ite of active osteogenesis

a,illa b+ suture (<' +ears

Antero :osterior 7evelo4 ent of :re a,illa influenced b+ /ntrinsic activit+ of "asolabial uscles e brananous bone 1o er < 4re a,illar+ suture Tongue :osture & 6unction Tooth develo4 ent

Cleft Alveolus #ue to

6ailure of fusion of M": & a,illar+ 4rocess =ssification centres in the 4re a,illa & a,illa cannot cleft alveolus Verti!al growth still active u4to &<%* +ears Tra%sverse & A) 9rowth &-> Co 4leted at 5+rs.

igrate & fuse

2,cess A: 9rowth of :re a,illa in Cleft Alveolus due to

Lac; of nasolabial uscle action overl+ing the 4re a,illa unrestrained growth of vo ero 0 4re a,illar+ suture 7isru4tion & widening of 4re a,illa 0 Lower li4 tra44ed behind the 4re a,illa a,illar+ suture Tooth buds in the cleft< inade?uate s4ace for correct align ent 4roclined

Aetiolo4.ereditar+ 5ere#itar2nviron ental

Less than #*> of cleft li4 & 4alate are of genetic origin

3naffected 4arents with a child who has a cleft have a chance of (#.#>) a second child with cleft /f one 4arent has a cleft there is ).@> chance that first born will have a cleft.

2nviron ental

/nfection (Aubella & To,o4las osis) 7rugs 0 steroid$ BB7$ anticonsulsants

8 o;ers /ncidence of Cleft %!'-* births in 38A Caucasians %!%*** births African A erican %!@*** births Asians %!-** births /solated cleft 4alate %!@*** births /solated cleft li4 ! )@> Li4 & 4alate (5> :alate @!% C! D 8ide < Left ! Aight! Bilateral (!)!% a+ Co 4laints of 6ood or fluid co ing out of their nose /nabilit+ to blow balloon E suc; a straw A 4ersistent s ell E discharge fro :oor s4eech nose

:atient

case)

/nabilit+ to clean their teeth in cleft area :atient a+ Co 4laints of 7eca+ed E defor ed teeth in cleft area Missing E e,tra teeth in cleft area Lac; of bone su44ort for teeth in cleft area :oor align ent of teeth Mobilit+ & overgrowth of 4re a,illa in bilateral case Lac; of su44ort for the ala$ base of the nose & li4 (Colu ella in bilateral

Aationale for Closure of Cleft Alveolus

To 4rovide stabilit+ for Mainl+ in

a,illar+ arch

obile 4re a,illa 0 bilateral case

/n Lefort / osteoto + 0 eas+ to advance a,illa in one 4iece To close oronasal fistula To construct 4+rifor nasal s+ etr+ ri & to 4rovide a better

To 4revent inferior turbinate 4rola4se into cleft. Aationale for Closure of Cleft Alveolus 2stablish ent of functional nasal airwa+ To su44ort accurate nasolabial reconstruction :eriodontal su44ort for teeth lining the cleft =ral & dental health i 4roved 84eech i 4roved / 4roved orthodontic result :rovide bon+ su44ort for i 4lant 4lace ent

Ti ing of AB9

:ri ar+ AB9 0 7one in @ +ears of age 6i% !o%7u!tio% 8it" li9 & 9alate !losure: 2arl+ AB9< @ 0 ( +ears of age before lateral eru4tion 8econdar+ AB9! ' to %@ +ears of age before cus4id eru4tion eru4tion

Late 8econdar+ AB9! After %@ +ears 0 canine :ri ar+ AB9 Advantage 2arl+ a,illar+ arch stabiliFation with out colla4se / 4roved arch for

Teeth adGacent to cleft eru4t into grafted bone. 7isadvantage Ma,illar+ growth affected (8agittal & Transverse 9rowth ) Co 4ensator+ changes in andible increased lower facial height

Aeasons for Ma,illar+ 9rowth 7isturbance

7isru4tion of vo er 0 4re a,illar+ suture 2,tensive uco4eriosteal stri44ing scar for ation 1o erine fla4 disru4tion

2arl+ 8econdar+ AB9

@ 0 ( +ears of age

To 4rovide su44ort for eru4tion of laterals 7isadvantage 8ignificant transverse growth and sagittal growth a+ be affected

8econdar+ AB9

&<%% +ears ost co onl+ done before eru4tion of canine When ; to @E)rd of canine root has for ed H =nl+ vertical growth re ains at this age. :h+siological igration & s4ontaneous eru4tion through grafted bone observed.

.ow to 4roceed a case of cleft AlveolusI .istor+ & :h+sical 2,a ination! 6ocused e,a ination on

An+ 4revious re4air =ro nasal fistula Alar su44ort 8iFe of alveolar defect

Mal 4ositioned teeth in cleft region Align ent E cross bite of teeth

:osition &

obilit+ of 4re a,illa

Ade?uac+ of soft tissue for tension free closure =ral h+giene Aadiogra4hic 2valuation

=:9 =cclusal view :eri a4ical view

:re 8urgical :re4aration of a :atient

The :re a,illar+ 8eg ent in bilateral case stabiliFed b+ arch wire$ 8ince obile 4re a,illa will cause the grafted bone fail to consolidate.

=ral .+giene :ro4h+la,is :re 8urgical :re4aration of a :atient =rtho treat ent & align ent of arch <Correction of cross bite

8u4ernu erar+ or Aetained 7eciduous Teeth in cleft area should be re oved atleast ( 0 5 wee; before surger+ to ensure ade?uate width & continuit+ of soft tissue fla4s.

Treat ent o4tions for cleft alveolus

Bone grafting :eriosteo4last+ boneless bone graft 9ingivo 4eriosteo4last+ 7istraction osteogenesis

=:T/="8 6=A AB9 A3T=92"=38 /L/AC B="2 A/B T/B/A CAL1AA/3M 8JM:.J8/8 ALL=:LA8T/C


cells

ALL=92"/C

CANCELLO< 2arl+ vasculariFation

CORTICAL BONE

"ot Co 4letel+ revascularised for @ onths Aelativel+ less

/ncreased nu ber of viable

A44osition followed b+ resorbtion

Aesorbtion followed b+ a44osition

bone

Co 4letel+ re4laced b+ new Ae ains as co 4osite of new & necrotic bone 9reater echanical strength

earlier

More susce4tible to infection

te

si

a#va%ta4es

#isa#va%ta4es

/liu

%. %.Large ?uantit+ %.Mild transient gait of cancellous bone. disturbance

@.7ecreased o4erative<ti e with @ tea a44roach. )."o growth disturbance #.2as+ to condense & 4ac; -.:roven successful result

@.7onor site re4orted in literature

orbidit+

site

a#va%ta4es

#isa#va%ta4es

@.calvariu

%./ncision hidden in hair bearing area @.Mini al 4ost< o4 disco fort

%.84arse cancellous bone @./ncreased o4erative Ti e ).Associated orbidit+ #.:oor results than iliu (less cellular) -.8tig a & fear for 4atient

8ite

Advantage

7isadvantage

). 8+ 4h+sis %.8a e o4erative field @.Aa4id 4ost<o4 recover+ )."o e,ternal scar

%.84arse a ount of cancellous bone @.Associated orbidit+ ).:oor result than iliac bone

#. ribs

%.Two tea a44roach 4ossible @.Mainl+ used in 4ri ar+ AB9

%.:oor source of cancellous bone @.:ost<o4<4ain ).1isible scar #.Associated orbidit+ -.3n 4redictable result

site -.:ro,i al tibia

advantage %.Ade?uate cancellous bone @.Mini al soft tissue dissection ).Aa4id 4rocure ent two tea a44roach 4ossible #. Mild 4ost<o4 disco fort

7isadvantage %.Less bone than iliac bone @./nterferes with growth (due to e4i4h+seal growth 4late)

T+4e allogenic

Advantage

7isadvantage

Co 4arable to "o osteogenic 4otential autogenous 7ela+ed incor4oration Allows for eru4tion of teeth Avoids donor site orbidit+

Allo4lastic

Avoids donor site 7ela+ed healing orbidit+ /nabilit+ of teeth to eru4t

:ost<o4erative instructions

Li?uid diet Avoidance of trau a to the site Antibiotics & nasal decongestants

' da+s

Meticulous oral h+giene with chlorhe,idine

Co 4lications

6ailure of bone grafts (Mainl+ in 4re a,illa) /nfection

obile

Wound brea;down & loss of graft (inco 4lete oralEnasal closure) 2,ternal root resorbtion Bone loss Aesidual fistula

8uccess of AB9

9ood nasal side closure

3se of ade?uate a ount of cancellous bone A water tight oral side closure

Ade?uate a ount of attached ucosa in the area of cleft for develo4 ent of nor al 4eriodontal attach ent of eru4ting canine 2arl+ secondar+ gingivo4eriosteo4last+

Li4$ nose$ soft 4alate closure at #<(

onths

of age (reduces the cleft width)

9:: at %5<)(

onths of age during the

stage of hard 4alate closure

Advantage <<Ae4airs the cleft in anato ic wa+ b+ a

4recise reconstruction of the functional atri,( uco4eriosteal atri, of a,illa) <<Avoids the need for AB9 7istraction osteogenesis

Advantage "o need for bone graft "o donor site orbidit+

Mini al surgical ti e "o hos4italiFation

Advantage <Bone height & width si ilar to nor al adGacent alveolus <7ental i 4lants 4ossible <6inal orthodontic tooth ove ent is good <Mini al orbidit+ 7isadvantage <Long treat ent re?uires 4atient co<o4eration &

close follow<u4 /"TA=73CT/="

/L/3M 8T/LL A2MA/"8 A 9=L7 8TA"7AA7 6=A A3T=92"=38 B="2 9AA6T A"T2A/=A & :=8T2A/=A CA28T 07="=A 8/T2 6A22 T/8832 9AA6T

83A9/CAL A"AT=MJ

7="=A 8/T2<A"T2A/=A /L/AC CA28T

8/T2 =6 .AA128T<B2TW22" T.2 A8/8 & T3B2ACL2 =6 T.2 CA28T (-c :=8T2A/=A T= T.2 CA28T) AA2A =6 9A2AT28T M27/=LAT2AAL W/7T.

83A9/CAL A"AT=MJ /72"T/6/CAT/=" & :A282A1AT/=" =6 A8/8 1AA/ABL2 A"AT=M/C A2LAT/="8./: =6 LC"T T= A8/8

W.J 7= W2 :A262A /L/3M A8 7="=A 8/T2I

/72AL 8=3AC2 6=A :MCB ./9. 83CC288 AAT2 /" AL12=LAA B="2 9AA6T/"9 M/"/MAL 7="=A 8/T2 M=AB/7/TJ TW= T2AM A::A=AC. :=88/BL2

T.2 A2:=AT27 C=M:L/CAT/="8 AA2! :A=L="927 :=8T =:2AAT/12 :A/". 82"8=AJ "2A12 7AMA92. 72LAJ27 .2AL/"9. .2A"/AT/=" =6 AB7=M/"AL C="T2"T8 :2A/T="/T/8 /L/3M 6AACT3A2 CL/CK/"9 & 9A/T 7/8T3ABA"C2 ALT2A27 B="2 C="T=3A C=M:L/CAT/=" & CA382 %.ernia <full thic;ness 4elvic defect @.:elvic fracture<graft harvest in close 4ro,i it+

to A8/8 & full thic;ness graft. ).L6C" inGur+<ano alous course &e,cessive dissection ediall+

.ae ato a 0 occult uscle bleeding and Large cancellous bleeding surface 9ait disturbance 0 e,tensive uscle stri44ing and i 4ro4er re4ositioning Contour defect 0 i 4ro4er re4osition of tra4 door :oor scar < 4oor suturing techni?ue$ infection and incision 4osition 7ela+ed wound healing 0 incision 4laced crestall+ :eritonitis E4aral+tic ileus 0 Bicortical E tricortical graftE breach in edial corte, or 4eriosteu

.=W T= A1=/7 C=M:L/CAT/=" I INCISION,

=12A T.2 CA28T<72LAJ .2AL/"9 M27/ALLJ < A/8K =6 7AMA92 T= LC"T(/L=M68<%&&() LAT2AALLJ < A28T.2T/CALLJ B2TT2A 8CAA :=8/T/="

.=W T= A1=/7 C=M:L/CAT/=" I

2MC288/12 M38CL2 7/882CT/=" M27/ALLJ < A/8K =6 7AMA92 T= LC"T :A=:2A A2:=8/T/=" =6 T.2 =8T2=BLA8T/C 6LA: 0 T= A1=/7 C="T=3A 726=AM/TJ .=W T= A1=/7 C=M:L/CAT/=" I

:A=:2A A2:=8/T/="/"9 =6 M38CL2 & 6A8C/A LATA < T= A1=/7 9A/T 7/8T3ABA"C2 83BC3T/C3LAA 83T3A2 < 6=A B2TT2A 8CAA

C="CL38/="

/n our stud+ there were "o gait disturbance "o chronic 4ain "o herniaEA:. "o 4rolonged hos4ital sta+ "o orbidit+ other than scar & contour defect on 4al4ation.

C="CL38/="

We conclude that$ anterior iliac crest 4rovides an ade?uate harvest of cancellous bone chi4s for AB9. With ade?uate ;nowledge of surgical anato + & consistent surgical techni?ue$ there is a lower incidence of donor site orbidit+