Alveolar Bone Grafting

Introduction
 ABG introduced in the 1980s
 ABG in mixed dentition, before eruption of permanent canine, is now established as the treatment for the
residual alveolar defect in patients with CLP. First described by Boyne and Sands 1972.
 Medullary bone from distant site (most commonly iliac crest but sometimes tibia) is placed in alveolar
defect. Within 3/12 of successful surgery, grafts appear indistinguishable radiologically and behave clinically
as normal alveolar bone
 Medullary bone from distant site (iliac crest/ tibia/ mandibular symphisis or cranium)
 Carried out in the mixed dentition before the eruption of the permanent canine

Aims of alveolar bone grafting

To eliminate the bony alveolar defect and provide:
1. Permit eruption of the permanent canine in the cleft site into sound bone.
2. To provide bony support for teeth on either side of the cleft
3. To improve stability of the cleft segments, especially the mobile premaxilla in the bilateral cleft lip and palate
cases.
4. To facilitate fistula closure.
5. To obviate or minimize the need for prosthetic replacement of teeth in the cleft site.
6. To improve the contour of the alar base

Timing
 Before the eruption of the permanent canine relating to the cleft side
 When one half to two thirds of the canine root is formed, usually (8.5 to 10.5 years)
 Bone grafting after the eruption of the canine adjacent to the clefts still offers advantages but the success
rate is reduced (in the same way that periodontists struggle to graft PDL defects) particulary in BCLP cases
(Jia et al 1998)
 Upper lateral incisor often missing but the presence of a pegs -2 often absent but if small diminutive 2
present, earlier ABG may be useful
 Requires short course of ortho treatment to correct incisor X-bite and expand collapsed lateral segments.

Orthodontics Pre-ABG
 Quad-helix or Tri-helix most often used – Aim is to create the best possible access for the surgeon to place
the graft and reveal true extent of any fistulae
 Wide view of nasal floor and its repair is facilitated by ortho expansion
 In BCLP, proclination of incisors which are often severely retroclined is essential if proper vision and access to
palatal fistula is to be achieved
 A very thin bony covering of the 1 next to the cleft site is a common feature before bone grafting. Often just
lamina dura with no cancellous bone

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 In such cases the incisor should not be bodily uprighted because of possibility of bone loss and
fenestration of thin cortical lamina.
 Removing deciduous teeth prior to ABG may double the amount of attached mucosa!

Surgical Technique
 For grafting to be successful, nasal mucosal coverage, as well as oral mucosal coverage over ABG is essential
 Therefore necessary to utilise the mucosal lining of cleft to construct the nasal floor and either advance or
rotate tissue from the oral cavity to cover the oral side of the graft
 Bony margins of cleft must be completely exposed up to level of nasal floor to ensure good osseous
consolidation
 Nasal floor and piriform rim constructed, by approximating mucosal edges, to provide a firm base for nasal
cartilages
 Cancellous bone then packed into defect. Cancellous chips better than blocks of bone because of their
greater osteogenic potential and speed of revascularisation
 Because margins of cleft are hypoplastic, overpacking the bony edges is suggested

Review and Records

 Review 1 week, 3 weeks, 6 weeks, 12 weeks, 6/12 and 12/12 post surgery. Then annually until definitive
orthodontic treatment
 X Rays at 12/52 then 1 year post op, then annually
- upper occlusals (Taken at high angles – 70% horizontal) eliminate magnification

Assessment

Bergland Scale (1986)

 4 point semi quantitative radiographic scale measuring post-op interdental bone height
Gp1. Normal interdental bony height
Gp2. More than ¾ normal interdental bony height
Gp3. Less than ¾ normal interdental bony height
Gp4. No bony bridge at all
 for clinical purposes Gp 1 and 2 = successful, Gp3 +4 = unsuccessful
 however, still possible for bony defect to be seen at root apex but interdental bone height normal therefore
rated successful when graft is partial to failure led to development of Chelsea Scale

Chelsea Scale
 assesses position of bone within the cleft in relation to full length (Witherow et al 2002) of root surfaces
adjacent to the cleft and the cleft midline at 8 sites
- also ascribes a grade to appearance of bony bridge across cleft

Kindelan Scale (1997)

 4 point scale comparing % bony infill on cleft site using pre and post-operative occlusal radiographs

 Nightingale et al. (2003, EJO) compared above scales and reported none of the 3 demonstrated superior
reproducibility over the other 2 (either within or between observers)
 Scales tended to be more reproducible in mixed dentition, rather than permanent
 Neither occlusal nor periapical radiographs were found to be more useful in the post-op assessment of
success of alveolar bone grafting.
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