Alveolar Cleft Grafts
The alveolar cleft defect is usually not corrected in the original surgical correction of either the cleft lip or the cleft palate (Fig. 27-15 on pages 6..U-6-12). As a result, the cleft-afflicted individual may have residual oronasal fistulae in this area, and the maxillary alveolus will not be continuous because of the cleft. Because of this, five problems commonly occur: (1) oral fluids escape into the nasal cavity, (2) nasal secretion drains into the oral cavity, (3) teeth erupt into the alveolar cleft, (-1) the alveolar segments collapse, and (5) if the cleft is large, speech is adverselv affected . . Alveo’lar cleft bone grafts provide se~’eral advantages: First, tl1f~yunite the alveolar segments and help prevent collapse and constriction of the dental arch, which is especially important if the maxilla has been orthodontically
expanded, Second, alveolar cleft bone grafts provide bone support for teeth adjacent to the cleft and for those that will erupt into the area of the cleft, Frequently, the bone support on the distal aspect of the central incisor is
thin, and the height of the bone support varies, These teeth may show slight mobility because of this lack of bone support. Increasing the amount of alveolar bone for this tooth will help ensure its periodontal maintenance.
The canine tends to erupt into the cleft site and, with healthy bone placed into the cleft, will maintatn good periodontal support during eruption and thereajter. That third ‘benefit of alveolar cleft grafts is closure of the oronasal fistula, which will partition, the oral and nasal
FIG. 27-11 Variation of von Langenbeck operation for concomitant hard and soft palate closure. It
uses three-layer closure for soft palate (i.e., nasal mucosa, muscle, ora! mucosa) and two-la ..-er closure
for hard palate (i.e., flaps from vomer and nasal floor to produce nasal closure, palatal flaps for UI ,Ii closure).
A, Removing mucosa from margin of cleft. B, Mucoperiosteal flaps on hard palate are developed;
note lateral releasing incisions. C, Sutures placed into nasal mucosa after development of nasal Ilaps
from vomer and nasai floor. Sutures are placed so that knots will be on nasal side. D, Nasal mUCO~Jhas
been closed. E, Frontal section showing repair of nasal mucosa. F, Closure of oral mucoperiosteum
FIG. 27-12 VornerIlap technique for closure of hard palate cleft (bilateral in this case). A;lncisions
through nasal mucosa on underside of nasal septum (i.e., vomer) and mucosa of cleft marqlns.
B, Mucosa of nasal septum is dissected off nasal septum and inserted under palatal mucosa at margins
of cleft. This is one-layer nasal closure orily. Connective tissue undersurface of nasal mucosa will epithelialize.
This technique, because it does not require.extensfve elevation of palatal mucoperiosteum, produces
less scarrtriq with attendant growth restriction.
cavities and prevent escape of fluids between them. Augmentation of the alveolar ridge in the area of the cleft is . a fourth advantage, because it facilitates the use of dental prostheses bycreating a more suitable supporting base. A fifth benefit is the creation of a solid foundation for the
lip and alar base of the nose. It has become evident that the alveolar cleft-grafting procedure itself creates a favorable change in the nasal structure, because the tissue at the base of the nose become supported after alveolar
grafting, whereas before the graft they had no solid osseous foundation. Therefore the alveolar graft should be performed before nasal revisions.
Tinting of graft procedure. The alveolar cleft graft is usually performed when the pati .nt is between ages 7 and 10. By this time a major portion of maxillary growth has occurred, and the alveolar cleft surgery should, not
adversely affect the future growth of the maxilla. It is important to have the graft in place before the eruption of the permanent canines into the cleft, thus ensuring -their peri:odontal support. Ideally the grafting procedure
is performed when one half to tWQthirds ofthe unerupted canine root has formed.Orthodontic expansion of the arch fore or after the procedure is equally effective; how “~r, some’ surgeons prefer to expand before bone graft: _OJ so that access into the cleft area is facilitated at surgle Intact each side must cover bone grafts placed into the alveolar cleft. This means that naps’ nasal mucosa, palatal mucosa, and labial mucos a all be eveloped and sutured in a tension-free, watertight mariner to prevent infection of the gl aft. The soft tissue incisions for alveolar cleft grafts vary but in’ each procedure these conditions are met (Fig. 27-16 on p.lge 643). – The bone placed into the alveolar cleft is usually obtained from the patient’s ilium or cranium however some surgeons are using allogeneic bone (i.e., omologous bone from another individual). The grafts are made into a particulate consistency and are packed’ into the defect once the nasal and-palatal mucosa’ have been closed. The labial mucosa is then closed over the bone graft. In time these grafts are replaced by new bone that is indistinguishable f-om the surrounding alveolar process (see Fig. 27-1” )rthodontic movement of teeth into the graft sites is possible, and eruption of teeth into them usually proceeds unimpeded.