Current Methods for the Treatment of Alveolar Cleft

Abstract

Alveolar cleft is a tornado-shaped bone defect in the maxillary arch. The treatment goals for alveolar cleft are stabilization and provision of bone continuity to the maxillary arch, permitting support for tooth eruption, eliminating oronasal fistulas, providing an improved esthetic result, and improving speech. Treatment protocols vary in terms of the operative time, surgical techniques, and graft materials. Early approaches including boneless bone grafting (gingivoperiosteoplasty) and primary bone graft fell into disfavor because they impaired facial growth, and they remain controversial. Secondary bone graft (SBG) is not the most perfect method, but long-term follow-up has shown that the graft is absorbed to a lesser extent, does not impede facial growth, and supports other teeth. Accordingly, SBG in the mixed dentition phase (6-11 years) has become the preferred method of treatment. The most commonly used graft material is cancellous bone from the iliac crest. Recently, many researchers have investigated the use of allogeneic bone, artificial bone, and recombinant human bone morphogenetic protein, along with growth factors because of their ability to decrease donor-site morbidity. Further investigations of bone substitutes and additives will continue to be needed to increase their effectiveness and to reduce complications.

Keywords: Alveolar bone grafting; Bone morphogenetic proteins; Bone substitutes.

Fig. 1. Alveolar cleft repair

(A) Preoperative view of an unilateral alveolar cleft after the orthodontic alignment of maxillary segments and teeth. (B) The flaps were raised over the greater and lesser segments of the maxilla in the subperiosteal plane, and the cleft mucosa was separated from the labial mucosa. The author elevated the flap to the subperiosteal plane, leaving little gingival attachment. (C) Iliac cancellous bone graft was packed within the cleft defect. (D) The larger posterior mucoperiosteal flap was transposed across the labial surface of the graft and sutured to the anterior flap without tension. When closing the mucosal flap, it was important to repair it with a watertight graft so that the roots of the teeth were not exposed.

Fig. 2. Unilateral alveolar cleft in a 12-year-old patient

(A) The nasal lining of the floor and the palatal flaps were repaired. (B) Autologous cancellous bone mixed with DBM was packed in the cleft. (C) Tension-free coverage was obtained by redraping the mucoperiosteal flaps. (D) Autologous bone and DBM. DBM, demineralized bone matrix.

Fig. 3. CT scans of alveolar cleft

(A) Preoperative and (B) 6-month postoperative CT scans of rightside alveolar cleft in an 11-year-old patient. CT, computed tomography.