**2. Alveolar bone grafting**

Alveolar bony defect is the main limiting factor for orthodontic treatment. Elimination of the bony defect is provided by alveolar bone grafting (ABG). Since the introduction of secondary alveolar bone grafting (SABG) in 1972, this technique has become an essential step in the overall management of patients with cleft lip and palate (CLP). Providing bone tissue for cleft has following benefits: [10, 12–21]


functions well and is capable of lifetime maintenance by routine oral hygiene and dental care. However, the underlying skeletal deformity that reflects intrinsic variation and the conse-

It is well known that facial growth in patient with CP is disturbed. Besides the intrinsic defect, surgery itself contributes to further disruption [3, 6]. A significant feature of facial growth in repaired CP patients is that the maxilla fails to grow at the same rate as the mandible during the adolescent growth spurt. Progressive midfacial retrusion is usually seen by the mid- to late teens. The results of the facial growth studies revealed the general characteristics of the individuals with UCLP: a short retrusive maxilla and vertical elongation of the anterior face,

Lack of the alveolar bone may give rise to a variety of problems, including oronasal fistula, fluid reflux, speech pathology, impaired tooth eruption, lack of bone support for the anterior teeth, dental crowding, periodontal recession and eventual loss of teeth, and maxillary and facial asymmetry. Alveolar defect also limits orthodontic treatment and/or prosthodontic

Thus, orthodontic treatment for children with cleft should aim to achieve an optimal occlusion and dentofacial esthetics within the constraints imposed by the underlying skeletal pat-

The integration of orthodontics into the overall treatment of CLP starts any point between birth and end of the teens and highly related to surgical procedures, including lip repair,

This chapter reviews current orthodontic approaches in relation with alveolar bone grafting

Alveolar bony defect is the main limiting factor for orthodontic treatment. Elimination of the bony defect is provided by alveolar bone grafting (ABG). Since the introduction of secondary alveolar bone grafting (SABG) in 1972, this technique has become an essential step in the overall management of patients with cleft lip and palate (CLP). Providing bone tissue for cleft

**1.** To permit eruption of the permanent canine in the cleft site into sound bone.

**2.** To provide bony support for teeth on either side of the cleft site.

There are two major factors which effect orthodontic treatment in patients with CLP:

quences of surgery severely restricts occlusal change [5].

a retrusive mandible, and a reduction in posterior face height [6–9].

alveolar bone grafting, distraction, and orthognathic surgery [5].

**1.** Facial growth disruption

158 Current Approaches in Orthodontics

**2.** Alveolar bone deficiency

rehabilitation [10–12].

(ABG) in nonsyndromic cleft patients.

**2. Alveolar bone grafting**

has following benefits: [10, 12–21]

**3.** To permit orthodontic tooth movement.

tern [5].

**8.** To improve the contour of the alar base.

The long-term success of the alveolar graft is crucial for providing and lifetime maintaining optimal occlusion and dentofacial esthetics in patients with CLP.

Postgraft stimulation of maturation through remodeling of the graft is extremely important and is provided primarily by natural tooth eruption. Thus, it is generally agreed that the optimum timing for ABG is in the mixed dentition stage (8–11 years), just before the eruption of the permanent canine in line with the cleft side [10, 13, 16, 19, 22–29]. There is no precise recommended chronological age but, when one-half to two-thirds of the canine root is formed [10]. Canines are mostly the reference teeth because lateral incisors in patient with CLP are frequently absent. However, if lateral incisor is present, earlier bone grafting can be indicated at an age around 7–8 years. It has been found that the success rate is significantly reduced when ABG is performed after eruption of the canine. Resorption of the bone graft is a common situation, and the success of ABG depends on several factors. The periodontal health of the surrounding graft tissues, the experience and ability of the surgeon, and graft material are also shown to be the general factors determining success [13, 19, 20, 23, 30, 31].

The importance of the orthodontist in planning, preparations, and follow-up around ABG procedure is also widely recognized. Successful alveolar bone grafting necessitates a joint orthodontic and surgical involvement pre-, peri-, and postoperatively [10, 32, 33].

Before treatment, orthodontists should be able to explain the predicted outcome of bone grafting to patients and their parents [34].

At that point, diagnostic information is very important for planning pre- and post-orthodontic management.
