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Unilateral Cleft Lip: Bone Graft Options?

posted in Patient Questions on Dental Implants, advice

« Replacing Congenitally Missing Lateral Incisor? | Torque Wrench Clarifications? »

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Kirstin, a patient, asks:
I have a unilateral cleft lip and palate. I currently have surgery scheduled in a month to do a bone graft from my hip to my mouth to prepare for implants. 8 years ago the same procedure was done and didn’t take. This time they intend to use a new growth hormone, but I remember the pain from last time. For about 6 years there has been discussion about using an artificial bone matrix, but when I last spoke with my surgeon he didn’t want to do it. Are there viable options other than the graft from the hip or is this the best choice? Is there anything specifically wrong with artificial bone matrix? How has the clinical data been for using growth hormones with the graft? Anything else I should now given my condition? Thanks.

9 Responses to “ Unilateral Cleft Lip: Bone Graft Options? ”

• JW August 26th, 2008

  
  

  Your own bone is considered the Gold Standard of bone grafting and would provide the best chance of success. However, these are wuestions you should be asking your surgeon (or staff). If your surgeon says he’s not comfortable with it, trust him. He may not gave used it before, or he may not like some of the results others are getting. Ask questions now and that prevents problems in the future

• Dr. Mehdi jafari August 27th, 2008

  
  

  While surgically treating the alveolar clefts, graft intake depends absolutely on the features of the defect and on the age of patient.Considering the fact that sometimes the lateral incisor or canine teeth need to be moved via the cleft area orthodontically, and the grafts are always set to wrap-up the naked dental roots adjacent to the defect, the tissue is always harvested from the iliac crest.It is only the autogenous viable osteogenic harvest that allows the erupting teeth to move into the cleft space and find their proper place in the maxillary dental arch. No part of the mandible or any other membranous bone can provide the needed amount of good quality cancellous bone without imposing a burden on the patient or deforming the harvested site. It is necessary to use more than a triple the amount of graft at least. The patient’s age respective to the size of alveolus can account for this fact. Harvesting even a large amount of cancellous bone graft through the inner side of the iliac crest is a relatively simple procedure and leaves only a 2 cm skin scar.

• Don Callan August 27th, 2008

  
  

  Being a member of the cleft palate team at the University of Arkansas Medical Sciences, we have found the young patients do very well with the Autograft, However, after the age of 18 the allografts work great with the proper membranes and there is very little post-op discomfort. One of the most important factors is the surgeon, check him out.

• XAV August 27th, 2008

  
  

  Iliac bone is highly reliable in cleft grafts thus your surgeon’s recommendation. In addition to the comments above, the condition of the soft tissues and the size of the defect impacts heavily on the outcome of alveolar cleft reconstruction. Appropriate closure that ensures vascularity, and measures that will promote adequate stability of the graft during healing are necessary. It interests me what factors contributed to graft failure and what strategies will be employed to ensure a different result. Good luck.

• Bach Le August 31st, 2008

  
  

  I have used mineralized allograft to treat 2 large alveolar clefts in adult patients with very good success. Both patients had implants placed and restored successfully with stable peri-implant bone. One patient is now in her 4th year follow-up. In fact, this patient had a history of a failed autograft treated previously by me. I recognize that 2 cases is hardly enough to draw a conclusion, but I do believe that this needs further research. This case series will be published in the J. Oral Maxillofacial Surgery. I find that there is one inherent problem with iliac crest bone…too much resorption and never enough for placement of an implant without further grafting. BMP is also a viable option for the treatment of alveolar clefts in children (without having to use hip bone). A case series was recently published by Herford and Boyne from Loma Linda in the Journal of Oral & Maxillofacial Surgery. The only problem with BMP growth factor is that is lacks a good carrier to provide adequate tenting of the defect.

• prof.Dr.Hossam Barghash September 1st, 2008

  
  

  Dear kirstin, when we think about grafting alveolar cleft,we have to decide first what is the aim.if it is for allowing eruption of the canine,then autogenous bone is a must cos it allowe the process of eruption,but in your case ,the grafting process is done for future implant,so the planning is like what usually we do for implant,with the most important point to be sure of the closure of oronasal fistula. I think you should discuss all this points with your surgeon,knowing the points of view.Allo or mixed graft still an option in your case

• Dr JB SEIGNEURIC September 1st, 2008

  
  

  I’m member of french cleft team in Paris.
  I pratice alveolar bone grafts since 2000 in young patient (6-10 years old) and adults.
  Of course autograft of cancellous bone is the best way to perform this surgery. Cancellous bone can be harvested in other donor sites with success and less pain and scare (from the tibia for example).
  But there is another way to perform secondary or tertiary alveolar bone graft to prepare implants.
  Bone can be harvested in oral sites (like chin or ramus). Then the bone is milled to fill the alveolar defect.
  This kind of harvesting is safe, without scares of the skin and provides few pain (near tooth extraction). I pratice this kind of harvesting since many years with good success.
  Regards.

• Richard Waghalter,DDS September 2nd, 2008

  
  

  I have taken a course from the Infuse bone graft (BMP) medtronics people. their clinician from Linda Loma U showed the use of infuse bone graft to completely heal a maxillary anterior cleft palate without the use of a second site(Donor site)

• Robert Gougaloff, DMD September 3rd, 2008

  
  

  Cortico-cancellous bone from the hip is still considered the gold standard by many surgeons, due to the great growth factor content of this graft material. However, as one of the posts has already alluded to, there is a new product available, which is a concentrated formulation of rhBMP-2 (bone morphogentic protein - 2), which many orthodedic surgeons have grown to love. This rhBMP-2 was originally discovered by a Dr. Urist and was shown to spontaneously grow bone in muscle tissue. Excellent results have been achieved with rhBMP-2. The only downside is it’s expense. The package we use for sinus lift surgeries can be anywhere between 4k and 7k depending on the quantitiy needed. I would ask your surgeon about this.

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