Dr. Fawzi Alqatami
Diplomate of the American Board of Orthodontics
Ministry of Health, Kuwait
If your child has a cleft that extends to the gingiva (gums) on one side in unilateral cases or on both sides in bilateral cases, he or she will need to have a bone graft augmentation in that area at some point in his or her life. The reason behind doing this in the cleft region is that there will be some teeth that will erupt, usually a lateral incisor (if present and not congenitally missing) or the canine. These teeth need to erupt and be surrounded by bone. Hence, when the cleft area lacks the bone necessary for the teeth to erupt into, we need to perform a bone graft procedure. The donor site of the bone graft is usually from the hip area.
Occasionally, the cleft area (unilateral or bilateral) would collapse due to the scar tissue that was caused by the palatal surgery repair at 12 months of age. This would require an orthodontic intervention to correct this collapse. Now, depending on the case at hand, the appropriate time for the intervention will be determined for each case separately by the Clinician. This leads the parents to raise the question: “When will my child need to have the bone graft surgery?” there is no short answer to this question, but my common answer to the parents is that “it depends!”.
As Clinicians, what are the factors that we need to take into account to decide on when to start?
- Position of the canine, or lateral incisor (if present) from a panoramic x-ray.
- Path of eruption of these teeth.
- Available space for these teeth.
- Presence of a crossbite in the anterior or posterior.
When the canine or lateral incisor is high and far away, this would delay the timing of the bone graft procedure. When the time for the bone graft procedure is decided, it is usually preceded by a short period of orthodontic treatment. The process would start by evaluating the width of the maxillary arch (upper arch) to check first if the expansion is needed. The two (unilateral) or three (bilateral) segments will need to be aligned before placing bone between them. The closest analogy to this concept is welding! When you want to weld two pieces of metal, you would want to align them first. In a similar fashion, the orthodontic treatment prior to the bone graft would align these segments before welding the pieces with the bone! Furthermore, if the spaces are collapsed, the Orthodontist will open the appropriate space for the incoming teeth. The period of this orthodontic treatment is usually 6 – 12 months.
Once your child is determined to be ready, he or she will be referred to the surgeon to perform the bone graft. The orthodontic appliance (braces) will still be on your child’s teeth. We will need to take appropriate x-rays prior to the referral. Your surgeon will give you detailed instructions with regards to the surgery and the post-op instructions. After your child is dismissed, we will need to repeat the x-rays within 2-3 months after the surgery to check the bone’s quality after the grafting. The orthodontic treatment of moving the teeth into the grafted site would usually resume 4-6 months after the surgery.
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