The most important part of cleft treatment

In my opinion, the secondary alveolar bone graft is the most important aspect of treatment for the cleft patient.

The bone graft closes the final communication between the nose and mouth, and it helps to stabilize the jawbone. Having an interruption in the jawbone, due to the cleft, can cause lack of stability and collapse of the arch. The teeth next to the area lacking bone will begin to migrate and tilt toward that area. Think of it like completing a circle. Having a cleft makes for a break in the circle, and the bone graft fills in the last portion of the circle and stabilizes everything .

When should this treatment be done?

This treatment should be done around the ages of 8 to 10. The reason for this timing is because we want to complete this treatment prior to eruption of the canine, which is next to the cleft area. Again, this helps to create arch stability before eruption of permanent canine teeth next to the cleft.

Where does the bone come from?

The bone is usually taken from the hip. This is called an autograft because it is a graft that is taken from your own bone. An autograft is considered standard of care because there is less risk for transmission of disease and should be accepted better since it comes from the patient instead of an outside source. The only down side is that you can experience pain for a bit while the donor site is healing .

Another option would be allograft bone, meaning it comes from a bone bank that collects cadaver bone. The bone is cleaned and disinfected through many processes, but there is always the slight chance of disease transmission. Also, this type of bone does not have all of the cells that are present in autografts to encourage bone growth .

What can go wrong?¹

1. Sutures can come undone, exposing the bone graft
   • once the bone graft is exposed, the part of the bone that is exposed is now dead and will come out either as one piece or in tiny pieces
     
2. Eruption of the canine within the bone graft
3. Infection of the graft site
   
4. Harm to teeth next to bone graft site
5. Complete failure of the bone graft, leading to communication between nose and mouth
   

It is, unfortunately, not uncommon for these grafts to fail. The surgeon is essentially placing bone into a hole that is not supported by structures around it. Also, there is a lack of blood supply to these regions because of scar tissue. Scar tissue is the result of the surgeries done to repair the cleft defect.

What happens if it does fail?

Don’t lose hope! When you read my story below, you will feel better about this. There are so many options that you can do in case of failure. And thanks to prosthodontists, they can be some pretty great options. Ready? Let’s go!

1. Try again
   • This is what most people do who have a failure. Yes, it stinks, but why not keep trying?
     
2. If you are an adult, and you really don’t want to try anymore, an obturator is a great option
   • Obturators will replace the missing teeth AND cover the hole where the communication exists
3. Complete orthodontic treatment, and try again
   • This would mean the next attempt would be in the early to mid- teenage years
4. Leave the defect as is, and replace missing teeth with a bridge or removable partial denture

And what if it succeeds?

I like the way you think!

1. Proceed with all of the steps outlined in Timeline of Events
2. Replace missing teeth once orthodontic treatment is completed
   • Dental implants can be placed when skeletal growth is complete

My story

I had an iliac crest graft in 1998, which failed. An iliac crest graft involves bone being taken from the hip. I remember feeling tiny granules of bone in my mouth as the stitches had opened up. I had another iliac crest graft in 2002, which also failed. I continued with my orthodontic treatment and proceeded to have the final surgeries involved with clefts, including nose and lip revisions.

Finally, in 2009, my last bone graft was successful, meaning an adequate volume of bone remained in place, but it was not taken from my hip. It had been cadaver bone and was covered by a metal mesh material to protect it and hold it in place. I had been freaking out the week after the surgery, so afraid it was going to fail like the others did. I remember going to my surgeon’s office almost every day (my poor mother), just so he could make sure it looked good. He looked right at me and said,

“It’s not going to fail”

That was all I needed. I didn’t go back until I actually had a follow-up scheduled, and the bone graft had been successful. Never underestimate the power of positive thinking. I swear it works!

About 5 months later, I had 2 dental implants placed where the bone graft had been. It had been planned, as explained in my Dental Implants post, so the implants were placed exactly where they needed to go. 

However, there was a slight complication. I could not wear my retainers made by my orthodontist while I was healing because they would not fit over the newly built up gingiva. I did not know what to do, but everyone said the most important thing was to have the bone graft heal. Ultimately, my teeth had moved and shifted because of not wearing the retainers. I had to undergo orthodontics again once I was done healing from the bone graft.

This is very important!!!

Please do not make the same mistake I did. Please make sure you go to a prosthodontist during the process so that the prosthodontist can figure these things out FOR you. Having someone like a prosthodontist on my team would have helped with maintaining the teeth in their positions and also giving me something to wear while healing to replace my missing teeth.

3 months later, I had my implants restored with crowns, and I had never been happier in my life.

This sounds like a pretty good ending!

Unfortunately, it didn’t end there. For 10 years, it was great. My confidence had soared, I made amazing friends, and I met the most wonderful man who is now my husband. You can read about what happened to my implants HERE. Long story short, I developed an aggressive infection, and they were failing.

In November 2017, I agreed to have another surgery…. 10 years after I thought I was done for good. I found an oral surgeon at UCLA who specializes in craniofacial patients, and he is also a plastic surgeon. Amazing!! He removed my implants and did a bone graft, taken from my hip, under general anesthesia. I was swollen and in a fair amount of pain for about 3 days.

After a week, the swelling had gone down, and my hip pain was almost gone.

However, a new problem came up at my 3 week follow-up. The sutures had loosened, and the bone graft was exposed. I kept the area very clean and rinsed with chlorhexidine 3 times a day. Chlorhexidine is controversial because while it does keep the area very clean, it also prevents tissue from growing. My surgeon had warned me that either a large amount of bone is going to come out or just the outside layer of bone will loosen after some time. I couldn’t handle this. More bad news, more complications, the possibility of more surgery. I had follow-ups every 2 weeks, and nothing was changing, which was actually a good sign. But I wanted something to happen so we could move on to the next step.

Finally, I stopped using chlorhexidine, and the tissue began to grow over the bone. It continued to grow.

At my 3 month follow-up, a tiny sliver of bone was loose, and there was beautiful tissue underneath. This was the best situation we could have asked for!

I had a CBCT taken, and a guide was made for proper placement of the implants. My husband, who is also a prosthodontist, planned the implants and designed the surgical guide. He also made retainers for me and a flipper for me to wear during healing.

What’s next?

On Wednesday, March 28th, I’m having 2 new dental implants placed. I’m SO nervous that when the surgeon sees the bone, it won’t be good enough for the implants.  But, I have to remember, positive thinking goes a long way!

I’m going to update you about everything so you’ll understand the ins and outs of dental implant surgery. Here we go! Wish me luck.

¹G. De Riu, V. Lai, M. Congiu, A. Tullio. Secondary bone grafting of alveolar cleft. Minerva Stomatol. 2004 Oct; 53(10): 571–579.