Surgery Spotlight: Bone Grafting of the Alveolar Cleft-Surgery Spotlight: Bone Grafting of the Alveolar Cleft

Surgery Spotlight: Bone Grafting of the Alveolar Cleft

Video Transcription

Bone grafting of the alveolar cleft is usually the last or one of the last steps in habilitating the cleft patient.  We usually choose to do this prior to definitive cleft rhinoplasty, believing that it's better to build the foundation of a house prior to putting the roof on.  We work closely with our orthodontic colleagues as far as timing is concerned. If the patient has orthodontics in place or if orthodontics are planned, we try to  avoid widening of the cleft with orthodontics prior to doing the procedure. We always use gingival and mucoperiosteal flaps to cover the bone graft.  Occasionally we'll use acellular dermal matrix and or an advancement flap of the adjacent gingiva.  The particular patient that we've illustrated the procedure with today is one who had both of those things and it worked out well.  We have been doing this procedure and it's worked well in our hands for over three decades and we would recommend it to you.  This is a patient that has an alveolar cleft as can be seen on the panorex and on the visual photograph here.  He did not have a secondary palatal cleft. This is the cleft in the alveolus is marked there. Here it is being examined with a probe.  The fistula extends up into the nose, a vestibulonasal fistula. We put our markings around the fistula and the buccal sulcus and along the cleft margins where we make our incisions.  We start the incision around the opening of the fistula into the buccal sulcus.  We use a little beaver knife for this. Then the incision is continued down along the cleft margin on the alveolus about midway between the labial side and the palatal side.  This is facilitated by using a little right angled knife that's also made by beaver that you can see here. It has a little round blade on it that facilitates this incision.  This is done on both the medial and lateral sides of the alveolar cleft.  And then the blade is used to begin the elevation of the gingival flaps. Then the same incisions are made on the palatal side.  A 15 blade usually works good for these, but the little right angled beaver knife can be used for the same purpose and works well.  We take this all the way back to the anterior margin of the cleft, wherever that is, usually around the incisive foramen, because by this time we usually have the posterior part of  the palate closed.  Once all the incisions are made, we use several different elevators. You can find which one works best for you. But we elevate the gingiva on both sides of the alveolar cleft.  Usually these are elevated at least a tooth or sometimes two laterally and medially.  We elevate this up onto the anterior maxilla to facilitate the closure of the vestibulonasal fistula.  Right here we're elevating the medial side over the central incisors.  Most of the time the lateral incisor is missing in these cleft patients. The cleft is cleaned all the way up into the nose, elevating soft tissues along the cleft  margin that extend up into the floor of the nose. We then use scissors to separate the margin of the fistula from the surrounding buccal  mucosa and underlying soft tissues. We try not to get into the fistula in doing this, but it's not a tragedy if you do.  The scissors are going along the cleft margin up into the floor of the nose here.  Again, mobilizing all that soft tissue up into the floor of the nose.  You can see the fistula extending up into the floor of the nose here. The periosteum on the palatal side is then mobilized posteriorly on both the medial and  the lateral sides of the alveolar defect.  The suture is then placed to take the caudal margin of the alveolar defect.  The fistula opening up into the floor of the nose to close this soft tissue part of the  fistula as much as possible. Since gravity is always working, it's unusual for a bone graft to work its way out of the  floor of the nose post-operatively, although that can sometimes happen. Again, we're just trying to get the cleft margins completely cleaned out so that when  we put the graft in there, it will be completely in touch with bone and not with soft tissue. Sometimes some excess soft tissue has to be excised in this area.  Here again, we're mobilizing palatal mucoperiosteum.  This is a little different angled elevator that's sometimes helpful for this purpose.  The cleft margins are mobilized all the way back to the posterior margin of the defect.  In this particular patient, it goes back to the incisive foramen. We want to get all the way back to the posterior margin so that when we start suturing it,  we get the very posterior part closed optimally. Here we're mobilizing mucoperiosteum off the medial side  all the way to the posterior margin of the cleft. Here you can see the complete alveolar cleft open with no soft tissue remaining between the bony margins of the cleft.  Then we start posteriorly and close the mucoperiosteal edges,  closing the palatal side of the cleft.  You start posteriorly and then bring that closure anteriorly up to the alveolar margin and the teeth.  Oftentimes, the little fishhook needle is helpful.  We use absorbable sutures for this closure.  I normally use a vicryl or a polysorb for this. The fishhook needle only comes on Ethicon's vicryl.  But we use other needles during the rest of the closure.  Again, we're just closing this from posterior to anterior up to the alveolar margin.  Then we start anteriorly at the superior margin of the alveolar cleft.  Again, starting in the buccal mucosa and closing that part together.  Then a suture is placed, as you see here, between the gingiva on the anterior part and the posterior part of the cleft.  You can see the buccal mucosa being brought down over the defect. Actually, it's the gingival tissue rather than buccal mucosa.  We close that together to close the inferior boundary of this alveolar cleft.  You just saw a little more soft tissue up in the cleft that would get in the way of bone graft approximating alveolar bone. We want to get that out of the way.  It looks like the anterior part of this closure is going to be a little tighter than I would like. We're going to do a gingival transposition flap.  We go over approximately three teeth and mobilize along the gingival margin the gingiva from the cleft over to about three teeth laterally or posteriorly.  Once we mobilize this completely up onto the anterior maxilla, the blood supply of this flap is obviously its attachment to the cheek lip and buccal mucosa.  You can see it mobilized here up onto the superior part of the alveolus and the inferior part of the maxilla. Then a relaxing incision is made.  This is about four teeth over.  We mobilize that completely so that it will move medially and anteriorly.  Freeing it from the soft tissue and from the anterior maxilla.  Keep a little traction on it with the tissue hook as you can see. And you can see here how that mobilized gingiva moves anteriorly and medially to close the  anterior part of the cleft. So here's the sutures in the buccal mucosa where the vestibulonasal flap used to be. Put a couple of stitches in there.  We try not to bring buccal mucosa down onto the anterior alveolus. We want this to look as nice as we can.  Also if you bring buccal mucosa down over the alveolar margin, it can interfere with tooth eruption. Once that defect is partially closed, we go to the hip for the bone graft.  We use lidocaine with epinephrine to partially devascularize the area that is going to be incised.  We move this skin from lateral to medial so that the ultimate scar ends up off of the iliac crest so that it won't be bothered or traumatized by belts or pants or skirts.  And then we take this straight down to the periosteum of the iliac crest and mobilize periosteum medially and laterally. Now there's usually a cartilage remnant on the surface.  We try to leave the cartilage down on the bone and just take this at the mucoperichondrial or mucoperiosteal level.  Then we use a 9mm orthopedic trefine to burr a hole into the anterior alveolus. Once it's engaged, we just twist and push.  You've got to be careful not to tear your rotator cuff doing this. But just twist that down until it's about 2 or 3 centimeters down into the cancellous bone part of the iliac wing.  You need to move it just a little bit so that that little bone tube breaks off. And you can see the graft in the end of the trefine.  You put the little plunger down through the trefine and push out the graft. You can see the graft there.  Usually cut off the cartilage part of this and put it back into the wound since the cartilage part doesn't accomplish anything in the alveolus.  You just cut that off with a pair of scissors and save it. And you can cut up the rest of that little plug that you've removed with the trefine  into smaller pieces that can be packed more readily into the alveolar cleft. You see that little cartilage piece?  Then you can use a curette and core out however much of that cancellous bone that you feel like is necessary to fill up the cleft.  You can usually get several cc's as you can see the amount that we're getting there. Usually put a little small drain in this wound. I just stick it down in the hole.  It's a little homemade drain that we make with a 19 or 21 gauge butterfly. Just cut a couple of holes in it and stick that down into the hole.  Release the cartilage plug and then close the periosteum back over it. Use absorbable sutures to do this with also.  And then close up the skin with a couple of layers of absorbable sutures. Once that's all closed, I don't put a stitch in the drain.  We just put a little tegaderm over it and hold the drain in place until the next day which is when we take it out.  Usually inject some marcaine in this area as well to help with pain control. But not disrupting so much of the bone there usually yields a result that's not particularly painful.  Then when we are back into the mouth and we're moving this gingival flap that we made immediately.  We move it one tooth forward from where it was and put a suture from the labial side of the alveolus onto the palatal side of the alveolus.  Put the suture just right through the interdental space. Grabbing gingival on the outside and palatal mucoperiosteum on the inside.  Here's another stitch going in between the two teeth there in the interdental space. And moving that gingival flap forward. Same thing here, suture through the dental papilla.  This secures this gingival flap in its medially and anteriorly transposed position. In this particular patient, the closure at the alveolar margin wasn't as secure as I  might have liked. So we're taking just a little piece of acellular dermal matrix and putting it into the inferior part of this alveolar cleft pocket.  So we've closed the palatal side. We've closed the superior part of the gingival side. We've put that alloderm down there to try to secure the inferior boundary a little better.  And then we just pack bone graft into the alveolar cleft. Try to do this fairly completely and really fill up this space and kind of pack it in place.  Need to be careful not to use suction here at all or you will suck up part of your bone graft. You can usually put a surprising amount of bone down in that cleft.  Pack it firmly but not overly tightly. You still got to get the anterior side closed and you need to keep that in mind as you're putting the bone graft in.  Use a little freer elevator here just to help with the packing. If you have the cleft cleaned out real well, it takes a surprising amount of bone to fill it up good.  One more little piece. You want to fill it up until the anterior surface of the gingival or of the alveolus is completely smooth and even across the anterior side.  We're also filling up the cleft underneath the alar base and packing this bone there as well.  And then after you've got all the bone graft in, we suture the palatal mucoperiosteum to  the transposed gingiva on the anterior side. Sometimes this is a 3 or 4 point suture to get these margins closed at the alveolar margin.  This can be the, and usually is, the most tenuous part of the closure and that's one reason for putting the Acellular Dermal Matrix in there.  I don't always do that, but probably at least half the time. And it's been helpful. Sometimes the ADM will get exposed a little bit, but the bone graft seldom comes out.  And it usually heals without any intervention. Then once that's closed, then we just finish the closure on the anterior side of the alveolus,  closing medial and lateral gingival margins together. And there's the closure. This is the post-op panorex showing good alveolar bone up into the nose.  And here's a photo showing the same area. This really facilitates orthodontic manipulation afterwards in order to get them as normal and occlusion as possible.  The question has been asked regarding the timing of bone grafting of the alveolus. There's not a hard and fast answer to that.  There have been a lot of timing triggers proposed, such as before the canine erupts or when the root has developed to a certain extent.  We work closely with our orthodontist and usually our bone grafting occurs between the ages of 8 and 12.  It depends a lot on dental development, on family issues, development of the child. And some of these families and children fall through the cracks and they're older rather  than younger when this gets done. The answer to the question I think is that you want to do it before there's any danger to loss of the canine tooth.  You want to bone graft that so that the tooth is stable and has good bone into which to  erupt or to grow. And to be stable and for orthodontics to take place in such a way that the canine can be  moved into proper position either next to the central incisor or a space left there  for an implant or a prosthesis. So that's the answer to the question. It's not a real hard and fast rule, but the orthodontists usually tell us when the proper time comes.  So thank you for the opportunity to produce this video and to present it to you. We would recommend this technique to you. Thank you.

Video Summary

The video discusses bone grafting for alveolar cleft repair, which is usually performed before cleft rhinoplasty to create a firm foundation. The procedure involves collaboration with orthodontists to ensure the timing is optimal, avoiding any widening of the cleft caused by orthodontics. The surgery uses gingival and mucoperiosteal flaps, sometimes supplemented with acellular dermal matrix or advancement flaps. The process involves marking the cleft, making precise incisions, elevating soft tissues, and preparing the site for bone graft placement. The graft is harvested, often from the hip, to fill the alveolar gap. The grafting aims to stabilize teeth and facilitate orthodontic movements. The preferred timing for the grafting is typically between ages 8 and 12, dictated by dental development and individual circumstances, ensuring stability for teeth like canines. The video highlights the successful outcomes over many years and recommends the technique.

Asset Caption

In this video, Charles Verheyden, MD performs a bone grafting procedure to close the alveolar cleft in a 15-year-old male. He has previously had a lip repair and the secondary palate was not cleft. This video illustrates gingival and mucoperiosteal flaps, and the harvesting of bone from the iliac crest. Cancellous bone is inserted into the pocket created by closure of the flaps on both the anterior and posterior surfaces of the alveolus. The final result is a closed cleft that stabilizes the maxilla which now has a smooth anterior alveolar surface. This procedure creates a foundation that facilitates orthodontic manipulation as a subsequent step.

Surgeon Charles Verheyden, MD

Source Baylor, Scott & White Disclosure Dr. Verheyden has nothing to disclose. This product is not certified for CME.

Keywords

Surgical Videos

Craniofacial

Pediatric

Charles Verheyden MD

surgery spotlight; Memben

bone grafting

alveolar cleft repair

orthodontics

gingival flaps

acellular dermal matrix

dental development