Alveolar Bone Grafting and Cleft Lip and Palate: A Review

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We read with great interest the recent article “Alveolar Bone Grafting and Cleft Lip and Palate: A Review.”1 We would like to take the opportunity to further expand on our experience with a new palatally accessed design to increase the success rate of secondary alveolar grafting.
Secondary alveolar bone grafting is a well-established technique in the management of patients with cleft lip and palate; any patient with a cleft should be considered for grafting. According to the thorough reviews by Koberg and Witsenburg, alveolar grafts were first attempted in the early 1900s using bone and soft tissue from the little finger.2 A variety of different donor sites have been used since then, with the most common being from the iliac crest, calvaria, mandibular symphysis, and tibia. Evidence suggests that oronasal fistula occurrence is greatly reduced when grafts are used. Bone grafts can provide a matrix for tooth eruption and a basis for shaping a closed dental arch, and may prevent transverse collapse of the anterior maxilla. Besides establishment of maxillary arch continuity with stabilization of the osseous segments, bony support of the nose and lip further leads to restitution and improvement of facial aesthetics.3 Regarding the technique, closure of the buccal side of the bone graft almost always requires the addition of more tissue to the area. A variety of advancement gingival flaps can be designed for this purpose. Releasing incisions were left and possibly disturbed maxillary development.4 However, instead of the flap tissues inside the cleft being designed for closure of the cleft, most were removed to keep proper containment for new bone. Here, we present a new design for closing the cleft by using the flap tissues inside the cleft without the releasing incision.
The morphology of the alveolus is similar to a trapezoid from the sagittal plane. The alveolar cleft is closed by four flaps, namely, the labial flap, the palatal flap, the nasal flap, and the cleft flap (Fig. 1, left). Two full-thickness palatal flaps were initially developed along the gingival sulcus on the palatal side extending into the cleft. An incision was made further into the cleft, separating the nasal mucosa from the gingiva. A similar incision was performed on the labial side. Careful flap elevation began with a sharp periosteal elevator along the labial surface of the alveolus identifying the piriform aperture. The nasal mucosa was elevated off the lateral wall of the nose and separated from the oral mucosa. The cleft flaps were elevated and pushed to the labial side (Fig. 1, center). The nasal mucosa was reflected into the nose and the periosteum out of the cleft so that new bone could be grafted onto the bone. A transition was created separating the nasal and oral mucosa so that the bone had proper containment (Fig. 1, right). [See Figure, Supplemental Digital Content 1, which shows a satisfactory outcome at immediate postoperative evaluation by this technique. Three measurement planes were selected and evaluated by cone beam computed tomography, named the nasal plane (right), the middle of the alveolar plane ( center), and the alveolar crest plane (left). All of the measurements were traced and performed by the same researcher using Image-Pro Plus 5.1 software (Media Cybernetics, Inc., Silver Spring, Md.); overfilling bone mass was removed. The entire defect was divided into the labial defect and the palatal defect, which is beneficial for analyzing the volume of new bone mass. On the basis of our cases, we achieved satisfactory outcomes on immediate postoperative evaluation by this treatment,
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