Alveolar bone grafting.

In the 1970s, Boyne and Sands published reports on a new technique for alveolar bone grafting. They recommended that only cancellous bone be used and that the procedure be undertaken in the mixed dentition prior to canine eruption. Alveolar bone grafting prior to canine eruption soon became a routine part of the protocol for 90% of European and North American cleft teams. Several uncertainties remain however, such as the specifics of the surgical and orthodontic procedures, type of bone and donor site, and the best way to manage the space in the dental arch. Probably the commonest timing of the bone graft falls between 8 and 11 years, however there has been a trend in some centres to graft earlier in the hope of better outcome for the unerupted incisors. The influence on maxillary growth of earlier grafting has not been ascertained. A wide range of donor sites has been use but iliac crest remains the most popular. Many teams perform orthodontics prior to grafting to correct severe segment displacement or align incisors to improve surgical access. Following grafting, absence of the lateral incisor may be managed with orthodontic space closure, placement of an implant or bridgework. The introduction of alveolar bone grafting probably represents one of the most significant clinical innovations in cleft care. Hopefully, advances in tissue engineering will replace the need for transplantation of autogenous bone, or will provide an in-situ biological solution to the generation of a continuous bone fill across the alveolar cleft.