Management of alveolar clefts

https://doi.org/10.1016/S0094-1298(03)00129-9Get rights and content

Section snippets

Anatomy/morphology

Consistent with the variability seen in clefting of the lip and palate, alveolar clefts exhibit a great deal of variability in their extent (Fig. 1). They may exhibit only a mild notch on the labial aspect of the alveolar process or present as a wide gaping space between the alveolar segments. In unilateral alveolar clefts, the cleft side of the maxilla is referred to as the lesser segment. Because of a lack of transverse stability, medial collapse is common. This process results in a crossbite

Dental patterns in alveolar clefts

Embryologically, the facial clefting process and the development of primary and permanent anterior tooth germs occur simultaneously. Therefore, it is not surprising that anomalous tooth formation is seen in the region of the alveolar cleft. This finding may be manifest by malformation, malposition, or absence of the lateral incisor or the presence of an additional tooth. In addition, the pattern seen in the primary dentition does not typically predict what will develop in the permanent

Treatment objectives

The goals of alveolar cleft repair have both functional and aesthetic purposes [8]. The functional objectives include closure of the nasolabial fistula, creation of a stable and continuous maxillary dental arch, improved support of teeth adjacent to the cleft site, allowance for eruption of teeth into the cleft site, provision of unrestricted orthodontic movements, and facilitation of oral hygiene Fig. 2, Fig. 3. With persistence of the nasolabial fistula, patients may experience chronic nasal

Timing of repair

The timing of repair of alveolar clefts has been controversial. From a chronologic standpoint, alveolar cleft repair is defined as primary and secondary. Primary repair occurs between birth and the age of 2 years. It is typically performed at the same time as the lip repair or as a separate operation before palate repair. Secondary repair is further divided into early, conventional or transitional, and late. Early secondary repair occurs after complete eruption of the primary dentition and

Orthodontic management of alveolar clefts

The orthodontist plays an essential role in the treatment of patients with alveolar clefts. Orthodontic treatment interventions are usually necessary at several stages of development in children with clefts. In infancy, maxillary orthopedics may be necessary to expand the collapsed lesser segment, to mold the anterior maxillary arch, and to reduce the alveolar gap. Before secondary bone grafting, further orthodontic treatment is generally required. This treatment usually involves placement of

Description of surgical technique

The patient is intubated using an oral Ring Adair Elwyn (RAE) endotracheal tube (Mallinckrodt, Inc., Glens Falls, New York) secured down the midline. Lidocaine with epinephrine is infiltrated around the periphery of the nasolabial fistula, in the labial and palatal aspects of the alveolar processes on each side of the cleft, and in the anterior hard palate. An incision is made around the labial component of the fistula, first within the loose mucosa. If the first incision is made after

Bone-graft donor sites

The gold-standard donor site in alveolar cleft repair is the iliac crest, typically harvested as a particulate cancellous bone and marrow (PCBM) graft [16]. The iliac crest provides the greatest volume of cancellous bone available among the commonly used sites and allows a two-team approach. Success rates using cancellous iliac bone are usually greater than 80% [23], [26], [27], [28]. The major criticism for using iliac crest as a donor site is significant postoperative pain and prolonged

Closure of alveolar clefts using maxillary osteotomies

As previously mentioned, the success rate for autologous bone grafting of alveolar clefts has been shown to be inferior in adolescents and adults (ie, after eruption of the canine teeth) [23], [26], [27], [28], [29], [30], [31]. Therefore, in older patients, other methods of treatment should be considered (Fig. 6). Approximately 25% of men with unilateral cleft lip and palate will have midface retrusion significant enough to require maxillary advancement [42]. Adolescent or adult patients may

Innovations in the repair of alveolar clefts

Platelet-rich plasma (PRP) is an autologous source of growth factors that has been shown to accelerate the rate and degree of bone formation in a bone graft [47]. It is obtained from autologous blood drawn immediately preoperatively or intraoperatively and differentially centrifuged into its basic components. The initial, or hard spin separates the erythrocytes from the plasma, which contains leukocytes, platelets, and coagulation factors. The second, or soft spin, which is done at a slower

Dental rehabilitation of the alveolar cleft

The final phase of treatment of alveolar clefts is the restoration of dental function and form. This step was traditionally addressed with either a conventional fixed bridge or an etched resin retained composite bridge (Maryland). These prostheses carry the disadvantage of violation of healthy tooth structure and the likely need for multiple replacements during the course of the patient's lifetime. In 1991, Verdi et al [61] described the placement of an osseointegrated implant into a grafted

Summary

Treatment philosophies in the management of alveolar clefts have changed greatly over the years. Currently, the most widely accepted protocol is for repair using autologous cancellous bone from the iliac crest during the stage of mixed dentition. Preliminary data suggest that the appropriate age for surgical repair during the secondary phase can be decreased without evidence of limitation of facial growth. Further long-term studies are necessary to support this protocol, however. With a

Acknowledgements

The authors thank their medical illustrator, Akhila Regunathan, for her contribution.

First page preview

First page preview
Click to open first page preview
View PDF

References (65)

  • S Sindet-Pedersen et al.

    Mandibular bone grafts for reconstruction of alveolar clefts

    J Oral Maxillofac Surg

    (1988)
  • J.C Posnick et al.

    Modification of the maxillary LeFort I osteotomy in cleft-orthognathic surgery: the unilateral cleft lip and palate deformity

    J Oral Maxillofac Surg

    (1992)
  • M Erbe et al.

    Long-term results of segmental repositioning of the maxilla in cleft palate patients without previously grafted alveolo-palatal clefts

    J Craniomaxillofac Surg

    (1996)
  • R Marx et al.

    Platelet-rich plasma: growth factor enhancement for bone grafts

    Oral Surg Oral Med Oral Pathol Oral Radiol Endod

    (1998)
  • R Ross et al.

    The biology of platelet derived growth factor

    Cell

    (1986)
  • T.J Nash et al.

    Effect of platelet-derived growth factor on tibial osteotomies in rabbits

    Bone

    (1994)
  • D.H Whitman et al.

    Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery

    J Oral Maxillofac Surg

    (1997)
  • H.L Tucker et al.

    Tibial defects: reconstruction using the method of Ilizarov as an alternative

    Orthop Clin North Am

    (1990)
  • M.S Block et al.

    Bifocal distraction osteogenesis for mandibular defect healing: case reports

    J Oral Maxillofac Surg

    (1996)
  • S.L.K Yen et al.

    Closure of a large alveolar cleft by bony transport of a posterior segment using orthodontic archwires attached to bone: report of a case

    J Oral Maxillofac Surg

    (2001)
  • J Hartel et al.

    Dental implants in alveolar cleft patients: a retrospective study

    J Craniomaxillofac Surg

    (1999)
  • N Hamamoto et al.

    Tooth autotransplantation into the bone-grafted alveolar cleft: report of two cases with histologic findings

    J Oral Maxillofac Surg

    (1998)
  • F.W von Eiselsberg

    Zur technik der uranoplastik

    Arch Klin Chir

    (1901)
  • E Lexer

    Verwendung der freien knochenplastik nebst versucher uber gelenkversteifung und gelenktransplantation

    Arch Klin Chir

    (1908)
  • R Drachter

    Die gaumenspalte und deren operative behandlung

    Dtsch Zschr Chir

    (1914)
  • G Axhausen

    Technik und ergebnisse der spaltplastiken

    (1952)
  • E Schmid

    Die aufbauende kieferkammplastik

    Ost J Stomat

    (1954)
  • T.P Tsai et al.

    Distribution patterns of primary and permanent dentition in children with unilateral complete cleft lip and palate

    Cleft Palate Craniofac J

    (1998)
  • A Suzuki et al.

    Maxillary lateral incisors of subjects with cleft lip and/or palate: part 2

    Cleft Palate Craniofac J

    (1992)
  • J Schrudde et al.

    Die primare osteoplastik der defekte des kieferbogens bei lippen-kiefer-gaumenspalten am saugling

    Zbl Chir

    (1958)
  • T Skoog

    The use of periosteum and Surgicel for bone restoration in congenital clefts of the maxilla: a clinical report and experimental investigation

    Scand J Plast Reconstr Surg

    (1967)
  • S Pruzansky

    Pre-surgical orthopedics and bone grafting for infants with cleft lip and palate: a dissent

    Cleft Palate J

    (1964)

    • Cited by (23)

    • Comparison of two preserved cartilage iliac crest cortical-cancellous bone blocks graft harvesting techniques in children: A prospective, double-blind, randomized clinical trial

      2023, Journal of Cranio-Maxillofacial Surgery

    • Alveoloplasty and the use of osteosynthesis material in the cleft lip palate

      2020, Anales de Pediatria

    • Alveolar cleft closure using a triangular flap with an M-shaped incision

      2019, Journal of Plastic, Reconstructive and Aesthetic Surgery

    • Alveolar bone grafting: Rationale and clinical applications

      2019, Dental Implants and Bone Grafts: Materials and Biological Issues

    • Cleft Palate Repair, Gingivoperiosteoplasty, and Alveolar Bone Grafting

      2016, Facial Plastic Surgery Clinics of North America
      Citation Excerpt :

      The degree of expansion should be limited in those with a bilateral cleft and a large palatal fistula. It normally occurs over a time period of 4 to 6 months28 and the device should be left in place for 3 additional months after the grafting has been completed during grafting consolidation. Presurgical expansion is typically preferred, although postsurgical expansion also is an option, especially with bilateral clefts to allow greater ease of closure of the palatal mucosa.

    • Treatment algorithm for bilateral alveolar cleft based on the position of the premaxilla and the width of the alveolar gap

      2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
      Citation Excerpt :

      Since Padwa et al. demonstrated that premaxilla repositioning with osteotomy after the ages of 6–8 years had no deleterious effect on midfacial growth, premaxilla osteotomy has gained wide acceptance and numerous supportive results have been reported.12–18 IDO, orthodontic treatment and orthognathic surgery have also gained popularity.1,2,19–28 Most of these treatment modalities have focussed on narrowing the cleft gap and placing the premaxilla in a position compatible with conventional ABG.

    View all citing articles on Scopus
    View full text
    Copyright © 2004 Elsevier Inc. All rights reserved.