A Comparison of Two Different Bone-Harvesting Techniques for

Secondary Alveolar Bone Grafting in Patients with Cleft Lip and Palate
C.M. MCCANNY, B.D.S., M.DENT.SCI., F.D.S.R.C.S. (ED.), M.ORTH. R.C.S.(ED.)
D.P. ROBERTS-HARRY, B.D.S., M.SC., F.D.S.R.C.P.S. (GLAS.), D.ORTH. R.C.S. (ENG.), M.ORTH. R.C.S (ENG.)

Objective: To compare the outcome of the trephine with open hip surgery
for alveolar bone grafting in cleft lip and palate surgery.
Design: The study was retrospective. The radiographs were assessed blindly
and on two separate occasions 1 week apart.
Setting: University Teaching Hospital.
Patients, Participants: In one group (group A), a trephine was used; in the
other (group B), open hip surgery was employed. Group A was comprised of
16 patients (nine with unilateral and seven with bilateral clefts of the lip and
palate) and group B, 13 patients (eight unilateral and five bilateral). The prime
entry criterion for inclusion in the study was that the canine tooth had erupted
into the graft site.
Interventions: A long cone periapical radiograph was taken of the erupted
canine tooth in the graft site.
Main Outcome Measure: The radiographs were graded from type I to type IV,
as described by Bergland et al. (1986a). A comparison was also made of the
eruption of the canine, postoperative morbidity, and length of stay in hospital
for each group.
Results: There was no statistically significant difference in the interdental
bone height (p 5 .61, MannWhitney U test). In group A, all patients had a
satisfactory clinical outcome (type I or II), and in group B, only one patient had
an unsatisfactory result (type III). The spontaneous eruption of the canine and
the number of nights spent in the hospital were also similar for both groups.
However, no patients in group A suffered postoperative complications, where-
as three patients in group B reported either a limp or postoperative infection
of the hip.
Conclusion: Both techniques produced satisfactory repair of the bony de-
fect, but the open hip surgery resulted in greater postoperative morbidity.

KEY WORDS: alveolar bone grafting, cleft lip and palate, open hip surgery, tre-
phine

Secondary alveolar bone grafting was introduced in 1972
by Boyne and Sands. The main objectives of it include the
following: (1) to stabilize the maxillary segments, especially
the mobile premaxilla in bilateral cleft cases (Turvey et al.,
1984), (2) to eliminate the need for a prosthesis or at least
improve the vestibular soft tissue relationship and alveolar
contour and thus facilitate the final prosthetic restoration (Jo-
hanson et al., 1974; Abyholm et al., 1981), (3) to close an
oronasal fistula if present and eliminate irregularities in mu-
cosal contour (Abyholm et al., 1981; Paulin et al., 1988), with
Dr. McCanny is Registrar in Orthodontics, Leeds Dental Institute, Leeds,
U.K. Dr. Roberts-Harry is Head of Department of Orthodontics and Consultant
Orthodontist, Leeds Dental Institute, Leeds, U.K.
Submitted March 1997; Accepted January 1998.
This paper was presented verbally at the British Orthodontic Society Meet-
ing, Scarborough, September 22, 1997.
Reprint requests: Miss C.M. McCanny, 18 Eden Drive, Leeds, West York-
shire, LS4 2TN, U.K.
subsequent favorable effect on speech if the fistula is large
(Enemark et al., 1985), (4) to provide bone into which the
canine and other adjacent teeth could erupt or be moved or-
thodontically and, in addition, give the adjacent teeth bony
support (Johanson et al., 1974; Boyne and Sands, 1976), (5)
to restore the canine eminence, thus providing bone support
for the alar base and possibly helping to eliminate nasal asym-
metry and relieve obstructed airways (Boyne and Sands, 1972;
Bergland et al., 1986a), and (6) to consolidate the maxilla so
as to facilitate secondary corrective surgery, such as orthog-
nathic surgery (Amanat and Langdon, 1991).
Fresh autogenous bone is the ideal bone graft material be-
cause it supplies living, immunocompatible bone cells essential
to osteogenesis (Albrektsson, 1980). The bone can be har-
vested from several sites. The ilium is used most frequently,
as access is easy and a large amount of bone can be obtained
from the area (Boyne and Sands, 1972; Johanson et al., 1974;
Abyholm et al., 1981).
This study assessed two different surgical techniques for

442

harvesting bone from the ilium. Specifically, this study was
designed to compare differences in outcome between trephine
and open hip surgery for secondary alveolar bone grafting in
patients with cleft lip and palate. Radiographic evidence of
bone height, eruption of canine teeth through bone grafts, post-
operative morbidity, and length of hospital stay were the out-
come measures utilized.
MATERIALS AND METHODS
Sample Selection
Prior to the study, ethical approval was sought and obtained.
The two experimental groups were drawn from two different
centers. Forty-seven consecutively treated patients who had al-
veolar bone grafts between 1986 and 1993 were identified for
consideration in this study. Group A consisted of 25 patients
from St. James University Hospital, where the trephine tech-
nique is utilized. Group B consisted of 21 patients from The
General Infirmary at Leeds, where open hip surgery is the
technique utilized.
The prime entry criteria for inclusion in the study was that
the canine tooth was erupted in the graft site. From this initial
sample, 17 patients were excluded, nine from group A and
eight from group B. In group A, three patients were too young,
as the canine teeth had not erupted; one patient had the op-
eration carried out at another hospital; and in one, implants
had been placed into the graft. Three patients had moved from
the area, and one could not be contacted. In group B, one
patient was too early, three had moved from the area, and four
could not be contacted.
The final study population included 16 patients in group A
(seven males and nine females) and 13 patients in group B
(eight males and five females). There were nine unilateral
cases and seven bilateral in group A, giving a total of 23 cleft
sites. As one of the canines in a bilateral case had not erupted,
it was not included, giving 22 cleft sites in this group. Group
B had eight unilateral cases and five bilateral, a total of 18
cleft sites.
Operative Details
All the bone grafts were taken from the iliac crest. Two
surgeons were involved: one surgeon performed all the tre-
phine operations for the patients in group A, and one surgeon
performed the open hip grafts in the group B patients. The
trephine technique used was based on that described by
McGurk et al. (1993), and the open hip technique was similar
to that described by Boyne and Sands (1972). For the bilateral
cleft patients in group A, the two sides were grafted approxi-
mately 6 months apart, whereas with the open hip technique,
both sides were grafted at the same operation. This was due
to preference of the operator.
The mean age at operation was 14 years (range, 9 to 30
years) in group A and 14.3 years (range, 7 to 25 years) in
group B. The mean follow-up was 43 months (range, 23 to 62
McCanny and Roberts-Harry, BONE-HARVESTING TECHNIQUES 443
months) for group A and 61 months (range, 13 to 95 months)
for group B.
Assessment of Outcome
The assessment of treatment outcome was evaluated from
radiographic examination. Those patients with suitable radio-
graphs in the hospital notes were not recalled. For the others,
an appointment and explanatory leaflet was posted.
The following criteria were assessed: (1) radiographic signs
of bony infill as observed on a postoperative periapical radio-
graph, using the long cone technique, when the canine tooth
had fully erupted. In patients with unilateral clefts of the lip
and palate, the contralateral tooth acted as a control. In two
cases, however, the canines had been extracted, so the upper
first premolar was used instead. For bilateral cases, the inter-
dental bone height between the adjacent teeth was used for
comparison; (2) the position of the canine, whether this was
reached spontaneously or required surgical exposure; (3) post-
operative morbidity and postoperative complications. As most
patients were unsure about some aspects, this was determined
from the hospital notes; and (4) length of stay in the hospital.
The bone levels were assessed according to the method out-
lined by Bergland et al. (1986a). This involves the measure-
ment of interseptal bone height, mesial to the cleft canine, from
periapical radiographs and is categorized into the following
groups: I septum height approximately normal, II septum
height at least three quarters of normal, III septum height less
than three quarters of normal, and IV failures if no continuous
bone bridge crossing the cleft could be identified even if sig-
nificant bone formation had taken place.
Each radiograph was assigned a randomly allocated number,
by an independent person, to be used for patient identification
at a later stage. One of the authors (C.M.C.) assessed the ra-
diographs blindly, on two separate occasions, 1 week apart.
For two patients, it was difficult to take long cone periapical
radiographs because of the anatomy of the palate, and an upper
anterior oblique occlusal radiograph was taken instead.
RESULTS
The results are as follows.
Radiographic Assessment
Trephine Technique (group A)
There was a successful outcome (type I or II) in 100% of
the alveolar grafts. Normal bone height (type I) was recorded
in 16 out of 22 (72.7%) cleft sites. Type II was seen in 6 out
of 22 (27.3%) sites (Fig. 1).
Open Hip Technique (group B)
There was a successful outcome (type I or II) in 94.7% of
these grafts (Fig. 1). Twelve out of 18 (66.7%) had type I, 5
444 Cleft PalateCraniofacial Journal, September 1998, Vol. 35 No. 5
FIGURE 1 Graphical representation of the percentages of patients in each type from group A and group B.
out of 18 (28%) had type II, and 1 out of 18 (5.5%) had type
III. The results are quoted in percentages to allow comparison
with other studies.
Eruption of the Canine
In group A, nine (39.1%) canine teeth had erupted prior to
the bone graft, and 10 (43.5%) erupted spontaneously through
the graft. Two (8.7%) canines had to be exposed, one (4.35%)
was extracted because of its unfavorable position, and one
(4.35%) remained unerupted at the time of this study.
In group B, eight (44.5%) canines had erupted before graft-
ing, and eight (44.5%) erupted into the graft. One (5.5%) ca-
nine was extracted, and one (5.5%) needed surgical exposure.
The two canines that were extracted were not included in the
radiographic assessment.
Postoperative Morbidity
In group A, one patient had dehiscence of the wound at the
recipient site but no morbidity of the donor site. In group B,
3 out of 13 (23%) experienced problems with the hip. One
patient (7.6%) reported a limp, and two (15.4%) had infected
hematomata of the hip, which resulted in a longer stay in the
hospital for one of the patients. The other patient developed
an infection after being discharged from the hospital.
Length of Stay in the Hospital
The average number of nights in the hospital was five for
group A (trephine), ranging from 4 to 15 for each hospital
admission. For group B patients, the mean hospital stay was
five nights (range, 3 to 10). The upper range for group A was
for a patient who had to undergo several procedures at the
same time (including lip revision). It was decided to exclude
this patient in calculating the mean because this would intro-
duce an unnecessary bias for this group. As this was a retro-
spective study, it was not possible to calculate the length of
operation for each technique.
STATISTICAL ANALYSIS
A Kappa statistic (Cohen, 1960) was used to assess intraex-
aminer reliability in examining radiographs. There was no sig-
nificant difference between the two readings done 1 week apart
by the author (k 5 0.83).
A MannWhitney U revealed that there was no significant
difference between groups A and B for the type of alveolar
bone height.
DISCUSSION
The results of this study showed that secondary alveolar
bone grafting for cleft lip and palate patients, as measured by
bony infill of the cleft, produced a clinically satisfactory out-
come in 39 of 40 patients (97.5%). There are no reports in the
literature comparing the success of the trephine method to
open hip surgery. Additionally, there are no studies docu-
menting clinical and radiographic results of the trephine meth-
od.
The results of this study compare favorably with those of
Abyholm et al. (1981), who studied 69 clefts where the canine
had erupted into its final position after secondary alveolar bone
grafting. The height of the interseptal bone was assessed to be
type I in 26 (38%) and slightly less than normal (type II) in
30 (44%). A septum of insufficient height (type III) had
formed in five (7%) clefts. Failures (type IV) were recorded
in eight (11%).
Bergland et al. (1986a) examined 292 grafted clefts (using
the open hip technique) and found that 50% of these were type
I, 40% type II, 7% type III, and 3% type IV. Better results
 McCanny and Roberts-Harry, BONE-HARVESTING TECHNIQUES
were obtained (i.e., a higher percentage in types I and II) when
the graft was placed prior to the eruption of the canine.
Bergland et al. (1986b) looked at 82 bilateral alveolar cleft
sites, 43 of which were grafted before and 39 after eruption
of the canine. Again, they reported a high success rate before
the canine had erupted, with 98% of the sample in type I or
II and only one in type III. Surgery carried out after the canine
had erupted produced 80% in types I and II, 10% in type III,
and 10% in type IV.
The results of the present study showed that only 2 of 23
(8.7%) canines, related to the cleft, required surgical exposure
in the trephine group. Ten of 23 (43.5%) canines erupted spon-
taneously, nine erupted before the graft, one was extracted,
and one remained unerupted. For the open hip group, 1 of 18
(5.5%) required exposure, 8 of 18 (44.5%) erupted into the
graft, eight erupted before the graft, and one was extracted.
These results compare favorably with those obtained by
Bergland et al. (1986a), who reported that 15% of their patients
required surgical exposure of the canine. A further study by
Bergland et al. (1986b) found that four patients (10.2%) re-
quired surgical exposure on one side. El-Deeb et al. (1982)
observed that 17 of 64 (27%) canines on the cleft side erupted
spontaneously, 11 of 64 (17%) required exposure alone, and
36 of 64 (56%) required surgical exposure and orthodontic
alignment to be in occlusion.
A later study by El-Deeb (1986) found that surgical expo-
sure was required in 20 of 34 (59%) cleft canines. Seventeen
of 34 (50%) of these required orthodontic alignment, and the
remaining 14 (41%) aligned spontaneously.
The study by El-Deeb et al. (1982) indicates that the mean
time between bone grafting and eruption of the canine was 3.4
years 6 1.6, which was significantly greater than a control
group (mean, 2.2 years 6 1.9). Hinrichs et al. (1984) reported
on 18 patients followed up for 2 to 8 years and found that
56% of the cleft-associated canines required surgical exposure
and 44% also required orthodontic assistance to erupt to a
functional occlusion. In the other studies, no indication is giv-
en of the time interval between bone grafting and the decision
to surgically uncover the tooth. Bergland et al. (1986b) re-
ported waiting 1 to 3 years until the premolars and canines
had erupted before recommencing orthodontic treatment.
Postoperative complications (infection of the hip or post-
operative limp) were recorded in 3 of 13 (23%) patients in
whom the open hip technique was used. In one of the cases,
this was determined from the hospital notes, and the two other
patients recalled their experiences. This is not a very scientific
method of assessing the morbidity, and it is probable that a
large number of patients could not recall their experiences be-
cause of the time interval between the operation and the time
of examination.
Details of pain should have been recorded contemporane-
ously using, for example, a visual analog scale or by recording
the amount and type of analgesia required. Restriction of mo-
bility, determined by an independent observer, as described by
McGurk et al. (1993) would have provided a more accurate
record of postoperative gait disturbance. In their pilot study of
445
11 patients, in which the trephine technique was used for bone
grafting, 81.6% of patients walked with a slight limp but with-
out assistance on the first day after grafting, and all patients
were walking with ease by the fourth day. The patient in the
current study in which the open hip technique was used, re-
ported a limp that lasted 4 to 6 weeks. No postoperative com-
plications were observed in the trephine group. The number
of patients in each group was too small to apply statistics in a
meaningful way.
A reduction in postoperative morbidity has also been de-
scribed by Caddy and Reid (1985) when the trephine was used.
They reported no problems with blood loss, hematomata,
wound infections, or other complications. All of the patients
were able to walk within 24 hours and some even on the eve-
ning of the operation. The main benefit of the trephine tech-
nique is that it avoids muscle stripping, thus making early am-
bulation possible (Tilley and Davis, 1984).
The mean number of nights in the hospital for each of the
two groups was the same (five). The patients with bilateral
clefts in group A (trephine) had two separate hospital admis-
sions. This is not a deficiency of the technique itself, but rather
the particular surgeons preference. The in-patient stay for both
groups was similar to that reported by Bergland et al. (1986a,
b), whose patients were usually discharged after 6 days, but it
was slightly longer compared to the study by Grillon et al.
(1984), in which the average stay in hospital was 3 days
(range, 2 to 6 days). Kortebein et al. (1991) reported an av-
erage stay of 3.1 days for iliac or calvarial grafts, which they
have currently reduced to 2 days. Caddy and Reid (1985) re-
ported an operative time between 15 and 25 minutes for tre-
phining. There have been no equivalent reports on the oper-
ating time required for open hip surgery.
CONCLUSIONS
(1) When the interdental bone height mesial to the cleft
canine was used as a means of assessing the outcome of the
graft, a MannWhitney U test revealed no statistically signif-
icant differences between the two surgical techniques.
(2) The morbidity of the two techniques would suggest that
the open hip technique had more postoperative complications,
including gait disturbance and wound infection.
(3) The average number of nights in the hospital was five
(range, 4 to 15) for the patients in group A and five (range, 3
to 10) for group B. For the bilateral cases in the trephine group,
this involved two admissions, two anesthetics, and two over-
night stays in the hospital.
(4) Satisfactory eruption of the canine was observed in both
groups. Only two (8.7%) canines in group A and one (4.35%)
in group B had to be exposed.
In conclusion, both techniques produced satisfactory repair
of the bony defect, but the open hip surgery resulted in greater
postoperative morbidity. This preliminary study would there-
fore suggest that the trephine is the preferred technique for
secondary alveolar bone grafting in patients with cleft lip and
palate.
446 Cleft PalateCraniofacial Journal, September 1998, Vol. 35 No. 5
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