Management of alveolar clefts
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.
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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 SurgeryAlveoloplasty and the use of osteosynthesis material in the cleft lip palate
2020, Anales de PediatriaAlveolar cleft closure using a triangular flap with an M-shaped incision
2019, Journal of Plastic, Reconstructive and Aesthetic SurgeryAlveolar bone grafting: Rationale and clinical applications
2019, Dental Implants and Bone Grafts: Materials and Biological IssuesCleft Palate Repair, Gingivoperiosteoplasty, and Alveolar Bone Grafting
2016, Facial Plastic Surgery Clinics of North AmericaCitation 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 SurgeryCitation 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.