| Review | Article |

Current concept in alveolar cleft management

Mohammad Sayedur Rahman Khan, Mei Shuang, Xiao Lin Liu, Sun Xu and Hao Fu Liang

Article Info Abstract

Depart e t of Oral a d Ma illofa ial The alveolar cleft is known as the developmental defect of bone in alveolar process of maxillae
Surger , College of Sto atolog , He ei which occurs in 75% of the cleft lip and palate patients with different types of clinical presentation
Medi al U i ersit , He ei, Chi a
like unilateral or bilateral and complete or incomplete. Secondary alveolar cleft reconstruction
For Corresponden e: with autogenic spongy bone grafting (osteoplasty) at the stage of mixed dentition is commonly
Moha ad Sa edur Rah a Kha accepted treatment to help in the maintenance of maxillary arch continuity, repairing of oronasal
drkha .saidur@g ail. o fistula, eruption of the permanent dentition, enhancement of nasal symmetry through providing
Re ei ed: O to er alar base support and improving speech. As of late, conflicting argument of alveolar cleft
A epted: No e er management is continuing regarding treatment planning with timing, graft materials, surgical
A aila le O li e: No e er techniques as well as methods of evaluation of the progress of alveolar osteoplasty. Now-a-days,
experiments have made for the application of allogeneic bone, artificial bone, and recombinant
ISSN: - O li e human bone morphogenetic protein (rhBMP), along with growth factors to diminish the donor-
- Pri t site morbidity associated autogenic bone grafting. The purpose of this review is to discuss about
pathogenesis and aetiology of cleft defects, surgical techniques, assessment of progress of alveolar
DOI: . / s uj. i . bone graft and proposed future materials for bone graft.

Cite this arti le:

Kha MSR, Shua g M, Liu XL, Xu S, with orofacial clefts mainly environmental and
Lia g HF. Curre t o ept i al eolar Introduction
left a age e t. Ba ga a dhu Sheikh genetic factors.6-8 The exogenous factors, such
Muji Med U i J. ; : - . Orofacial clefts have intrigued the clinician for as nutritional deficits, hormonal and metabolic
very long time. It is the second most common disturbances, immunological, infectious, chemi-
congenital malformation following clubfoot1 cal and drug effects, in only about 10% of cases,
Copyright:
The op right of this arti le is retai ted
and is characterized by the incomplete and the causative role of genetic factors is
the author s [Atri utio CC-B . ] formation of structures in the nasal and oral confirmable in about 20% of cases.9 Quality of
cavities. It is a group of conditions that includes life has been effected remarkable by orofacial
the lip, alveolar process and hard and soft clefts on the aspects of aesthetics, physical
Availa le at:
palates which may be occurred alone or (especially growth and mental) and functional.
. a glajol.i fo
together. World-wide, the rate of incidence is in
It is intricate and several steps procedure to
A Jour al of Ba ga a dhu Sheikh Muji between 1 and 2.2 per 1000, based on the
Medi al U i ersit , Dhaka, Ba gladesh geographical variations.2 Males with cleft lip repair the cleft structures for their normal
and palate and females with isolated cleft lip functioning and requires the involvement of
are usually found.3 physician from multidiscipline. After birth, the
treatment starts and continues throughout the
Orofacial clefts may be in the syndromic or non whole developmental period and often needs
-syndromic form. van der Woude is the most up to adulthood. Cosmetic repair of cleft lip
common syndrome usually related with the lip. and palate is taking precedence with excellent
Orofacial clefts usually are divided into the cleft result, while alveolar cleft repair is crucial for
lip with or without palatal involvement. The closure of an oronasal communication/fistula,
cleft lip may be unilateral or bilateral and providing bony support for adjacent teeth,
associated with an ipsilateral cleft of the stabilizing the maxillary segments,10 and also
alveolus. The alveolar involvement affects 75% improving support for the alar base.11
of the patients with clef lip4 and area between
This osseous defect of the alveolar process of
lateral incisor and the canine is the most
the maxilla requires a particular osseous resolu-
commonly affected. Primary cleft palate
tion that plays a special role in management.
consists of cleft lip, alveolar process and palate
Alveolar bone grafting is the method used to
(part of hard palate), while secondary cleft
add bone for correction of this defect. The ideal
palate composed of CP (rest of hard and soft
bone graft material is fresh autogenous bone
palate, from the incisive foramen).5
because it supplies immunocompitable bone
Aetiologically, several factors are associated cells which are essential for osteogenesis. 12
196 BSMMU J 2017; 10: 195-203

Harvesting of bone can be done from the several syndrome.21-22 Aetiology of orofacial clefts is
areas and ilium is the area of choice due to its multifactorial and relate with gene factors,
simple access and availability of huge amount of environmental factors, and teratogens.23-24 Genetic
bone.13-15 To surpass the donor site morbidity of the susceptibility is the major element of orofacial clefts.
autograft, assaying to get new alternatives by utili- Genetics account for 40–60% of orofacial cleft has
zing the synthetic bone materials, bone morpho- identified through Monozygotic twin studies.25 The
genic proteins (BNP) and allografts (demineralized most widely investigated variants are TGF and
freeze-dried bone allograft or mineralized freeze- MTHFR genes. Phenotypes significantly associated
dried bone allograft). with particular partial aneuploidies have identified
through the survey of chromosomal deletions and
This review will discuss the pathogenesis and
duplications and found 1q25, 3p21, 4p15, 4q32 and
etiology of cleft defects, technique of operation, and
10p15 regions significantly associated with orofacial
assessment of the progress of alveolar bone graft
clefts. However, the identification of candidate
and proposed future materials for the bone graft.
genes is made intricate by some factors like genetic
heterogeneity, departure from Mendelian
inheritance patterns, limited availability and the
Pathogenesis and Classification high cost of genomic tools, and the necessity for
very large datasets.21, 24, 26-32
In the developmental period, the nose, lips and
palate are divided into primary and secondary Orofacial clefts can be influenced by environmental
palates. During the gestation period, medial and factors. In early pregnancy, folate supplementation
lateral sides of the nasal pits grow to form medial has reduced the risk from 2533 up to 75%,34 although
and lateral nasal prominence respectively. not all studies have reported statistical
Maxillary prominence lies inferior and lateral to the significance.35 Deficiency of zinc causes orofacial
nasal pits, and grows medially to fuse with the clefts in animals36 and may increase risk in
medial nasal process and form the primary palate16 humans.37 Maternal diabetes may be associated
which will form the bony and soft tissue with non-cardiac defects including orofacial clefts.38
components anterior to the incisive foramen (nose, In case of maternal age, the chance of orofacial clefts
lips, prolabium and pre-maxillae).17 Maxillary is more in above 40 years old comparison with 20-29
prominence also exhibits two shelves-like out-ward years old.39 Maternal smoking enhances the risk of
growth (palatine shelves) which course in several orofacial clefts up to 30%40 and indirect smoke
directions and finally fuse to form secondary exposure does not seem to affect.41 It is contro-
palate16 which will be formed posterior portion of versial with maternal alcohol consumption, but
maxillae or hard palate and soft palate. This fusion binge drinking increases the possibility.42 Maternal
process starts from incisive foramen and continues exposures to effective teratogens like retinoic acid,
up to uvula positioned at midline and complete by phenytoin, and valproic acid43 have been noticed.
nine weeks of gestation.18 Other possible causative agents such as chemical or
radiation exposures, stress, maternal obesity or
When palatine shelves failed to fuse each other will infection and hormonal drugs.21, 44
lead to forming the cleft palate. On the basis of
anatomical disruption of the primary and secondary
palate, this abnormality can be categorized into
complete or incomplete; unilateral or bilateral. Management of Alveolar Cleft
Complete cleft palate indicates primary and
Management of orofacial clefts is perplexing in
secondary palate failed to unite which is usually
nature. An extreme multidisciplinary collaboration
related with unilateral or bilateral cleft lip.19
team with the maxillofacial surgeon, orthodontist,
Incomplete cleft palate indicates only primary
phoniatric specialist, otolaryngologist, speech
palate or secondary palate fail to unite which may
therapist, pediatrician and dentist is necessary for
be confined within the soft palate only or may
treating the patient from birth to maturity.44-46
continue through soft and hard palate up to incisive
Remarkable interaction is present between positive
foramen or may be limited within the primary
treatment outcome and the availability of
palate causing alveolar cleft.20
centralized care by the qualified devoted team.
Maximum patients are diagnosed only after birth,
although orofacial clefts can be detected from 17
Etiology weeks of intrauterine life by the help ultrasound
scanning techniques. Cleft status, patient’s age as
Orofacial clefts are etiologically differ in syndromic well as medical status are the factors to determine
and non-syndromic form. Non-syndromic form of the service and treatment option for orofacial clefts
orofacial clefts occurs in 70% of cases, while 30% patient. Surgery is the choice of treatment to repair
with orofacial clefts associate with additional the deformities usually started from few months of
congenital anomalies, known to be part of life and most of the cases also need additional
 BSMMU J 2017; 10: 195-203 197

surgical interventions later in life. Improvement of tissue can be harvested from various sites like iliac
aesthetics as well as function like feeding, speech, crest or wing, tibia, mandibular symphysis, radius,
breathing and hearing problems, can be achieved by calvarial bone, proximal humerus, distal ulna and
surgical treatment. Patients also need orthodontic ribs.61-66
care, speech therapy as well as social and psycho-
The autologous bone of the iliac crest is known as
logical services. Treatment plan of orofacial clefts
the optimum source and called as the gold standard
contains a range of services and needs to follow the
for the alveolar cleft reconstruction. Easy access and
manner from birth may up to adulthood stages.47-52
availability of sufficient amount of both cancellous
The alveolar osteoplasty is the process of fill up the and cortical bones are the remarkable benefits of
cleft gap with alveolar bone grafts, is the choice of harvesting bone grafts from the iliac crest over other
treatment with the aim of remove the oronasal donor sites.62, 63, 67 ‘Trephine’ technique can be
fistula, establishes maxillary arch continuity, limits helped to harvest sufficient amount cancellous
growth disturbance and movement of permanent bone68 as well as will be minimized hospitalization
dentition into the graft bone, enhance nasal period and duration of surgery, severity of pain;
symmetry, orthodontic movement and insertion of and painkiller use.69
dental implants, speech improvement, oral hygiene
At the beginning, it was a high expectation to
maintenance and improves of periodontal health.1
achieve a good result by the reconstruction of clefts
On the basis of development of palate, alveolar with the symphysis of mandible bone because of
osteoplasty can be classified into- similar embryonic origin (intramembranous), but
the actual problem is that only small amount of
1. Primary alveolar osteoplasty is made after lip
bone can be harvested from this site which is not
repair but before repair of the palate and should
sufficient for large unilateral or bilateral clefts
be done less than 2 years of age.53-54 Only rib graft
repair.60, 70, 71 However, having the chance of teeth’s
and calvarial bone graft are usually used for
root and mental nerve damage and the merits are
primary alveolar osteoplasty.55
rapid revascularization, low rate of resorption, same
2. Secondary alveolar osteoplasty is made after operative field, less post-operative pain.72
repair of the palate. It can be categories into early
Unremarkable scar formation, absence of functional
secondary (2-5 years), early (6-8 years) or late (9-
deformity, expediential surgical field, and availa-
12 years) mixed dentition, and late secondary
bility of sufficient amount bone are positive
grafting (after 13 years age).56-57
findings for reducing the operative adverse effects73
Complete palatal cleft and exactly aligned (end to as well as having chance of wound infection, small
end) alveolar segment are prerequisites for the amount of cancellous bone and intracranial compli-
primary alveolar osteoplasty, because of available cations (like hematoma, seroma, dural tear, dural
space between the maxillary segments will be exposure and cerebrospinal fluid leakage),74 while
exerted tension on flap over the graft bone and choosing calvarial bone graft. Study revealed that
enhance the possibility post-operative wound survival rate of cranial bone grafts is same as iliac
dehiscence, disclosure of graft and subsequent bone grafts which are approximately 85.0% and 84%
collapse of graft.53 Secondary alveolar osteoplasty respectively.75-76
helps to form the stable united alveolar arch as well
Regarding tibial bone graft in children, the outcome
as provide mature bony for supporting the tooth
is not satisfactory due chance of trauma causing
eruption.58-59 Secondary alveolar osteoplasty is the
hamper in growth.60 It is simple to harvest with
most acceptable and popular for treating alveolar
minimal bleeding, less post-operative pain and
cleft and commonly chose for the patient with age
permits quick ambulation as well as minimal period
of 6-13 years, usually before the permanent canine
of hospitalization; but the amount of graft bone is
eruption.
very small with an adult patient.
Various sort of bone graft material includes
It is one of the most common methods for alveolar
autografts, allografts, xenografts as well as bone
osteoplasty. Improper fitting with cleft bone, failure
graft substitutes are available to use in alveolar cleft
of eruption of teeth, insufficient support to alar
repair. Cortical, cancellous and cortico-cancellous
base; and chance of pneumothorax and pain
are different types of autogenic bone grafts.
postoperatively are the common complaints with
Alveolar cleft is considered as marginal bony defect
rib grafts.
and autologous cancellous graft play an important
role in formation and healing of bone due to its
property related with osteoconduction and act as Operative Technique
source of bony cells; is better to use for correcting
the defect.60 Available bone volume and morbidity The surgical procedure is performed under general
related to harvesting from definitive sites are anesthesia and the cleft area is infiltrated with
concerning issues for selection of donor area.60 Graft vasoconstrictor infiltration (1% xylocaine with epi-
198 BSMMU J 2017; 10: 195-203

A B C

Figure 1: Incisions are made on the buccal and palatal aspects of the alveolar cleft (A); For creating two full-thickness mucoperiosteal flaps
called medial and lateral mucoperiosteal flaps (B); Deposition of graft bone collected from donar site on the cleft region which finally lies
beneath the tension free sutured flaps (C)

nephrine) on the buccal and palatal aspect of the Major risks include infection, hematomas formation,
alveolar cleft. Two full-thickness mucoperiosteal different types of abnormalities (like subluxation
flaps are created by making incision (Figure 1A) and destabilization) of related joint, long-term (6
along the cleft margins which extend laterally months) standing pain, lack of sensation, abdominal
through the gingival sulcus of teeth up to molar contents herniation, fracture of related bones, and
teeth for getting sufficient mobility of flaps and abnormalities (like heterotopic) in hard tissues
raise the medial and lateral mucoperiosteal flaps regeneration (0.7 to 25%)77-79 and minor risks such
(Figure 1B). Then flaps are lifted from surrounding as problems with wound and infection, lack of
structures as well as from the area of the cleft. The sensation for short while and mild pain (4 to 49%).77
nasal mucosal layer is performed by interrupted
suturing while bony areas are fully visualized. Then
the palatal flaps are turned back and closed it by
Assessment of Progress of Alveolar
interrupted suturing for making a soft-tissue
pocket. Now, this isolated pocket is filled with Bone Graft
grafted cancellous bone collected from ilium. The The success of the bone graft can be assessed by
cleft defect should be compressed by the grafted clinical and radiological assessment. Clinical
bone to increase the number of bone particles per evaluation of alveolar bone graft includes eruption
unit graft volume. During inserting graft materials, of cleft teeth, periodontal status,80 alveolar height81-
level of acceptance is related to making the proper 84 and alar base support.80 Radiologically, the
shape of the cleft area comparison with nearest outcome will be assessed on the basis of appearance
surrounding structures for maintaining similarity as of the bone85 by using the Bergland scale and
well as aesthetic. Finally, flaps are closed by Chelsae scale86 which will continue at least six
suturing and need to make sure that sutured flap months postoperatively.
remains in lack of tension (Figure 1C).
Moreover, radiographic assessment seems to be
effective and superior to clinical methods.83-84
Accuracy of conventional (periapical, occlusal, and
Risk associated with Surgery orthopantogram) radiographs are not sufficient to
Risks associated with the alveolar bone graft get exact details of the cleft area for alveolar cleft
include graft resorption and alveolous notching assessment, CT scan should be used to overcome
may be happening with using of excessive graft these draw-backs in evaluating the alveolar cleft.87
materials; and exposure of wound by excessive CT scan and specialized software are necessary to
tension or trauma during recovery after surgery. assess the defect, for determining the amount to be
Study revealed that no more than 5% of patients are required for grafting as well as evaluation for post-
associated with graft failure.75 operative bone formation.88-89

During iliac crest harvesting, serious damage to

nearby structures rarely happens. If such damage
occurs, usually it is associated with different types Proposed Future Materials for Bone
of things mainly vessel and nerve. Nevertheless, Graft
diminished bone graft operation as minimum as
possible will diminish the risk related operation, Interest in bone graft substitutes arose due to
and appropriate technique of operation as well as surpass the side effect of autografts. A number of
making caution with vital structures of the opera- demerits are related with autogenous bone grafts
tive area are important while choosing bone graf- like donor site morbidity associated with hematoma
ting surgery. formation, infection, chronic pain, neurological
 BSMMU J 2017; 10: 195-203 199

deficits, iatrogenic fractures, and issues with evidence remains in vague, largely owing to the
cosmesis90-94 and availability of sufficient amount of vast array of available product types, and needs
grafting bone which is a momentous issue while further well-conducted prospective clinical trials
deformity is large. which might offer new exciting alternatives in the
near future.
Calcium phosphate graft materials like -tricalcium
phosphate ( -TCP) and hydroxyapatite known as
synthetic bone materials95-98 which have excellent
biocompatibility99 with easily producible, less
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