INTRODUCTION
Alveolar clefts are one of the principle sequelae of cleft lip and
palate and are defined as a discontinuity of the dental arch, having an
incidence of 0.18 to 2.50 per 1000 births.1,2 The
region of the alveolus most commonly affected lies between the lateral
incisor and canine teeth and result in the appearance of a ‘floating’
premaxillary segment if present bilaterally. Alveolar clefts occur in
response to divergence from normal embryological development during
frontonasal and maxillary prominence growth, contact and
fusion.3 A clinical picture comprising of facial
growth disturbances, nasal reflux, chronic periodontal inflammation,
speech disturbances and an unsightly aesthetic appearance is frequently
observed.4,5 With recent advancements and innovative
techniques in reconstructive surgery aimed at correcting such defects,
the quality of life of such patients can be improved significantly.
Alveolar bone grafting (ABG) was described at the beginning of the
20th century as a surgical intervention to be employed
in reconstruction of alveolar clefts.6 However,
success rates were initially low and varied tremendously depending on
the age at which it was performed, the type and source of bone used and
the surgeons expertise. With familiarity of the procedure increasing in
recent times, ABG is now recognized as the treatment of choice in
patients with alveolar clefts secondary to cleft lip and
palate.5 It remains a complex procedure requiring
meticulous planning and flawless execution by a multidisciplinary team
consisting partly of craniofacial orthodontists and oral and
maxillofacial surgeons.7 ABG involves reconstruction
of the alveolar defect through provision of bone (ideally autologous)
from a donor site that is then transferred to ‘fill’ in the deficiency
at the recipient site.8 Despite great developments and
improvements in the surgical technique the matter of the ideal source of
bone graft material still remains controversial to this
day.9
Presently, bone from the iliac crest is widely considered the ‘gold
standard’ due to its potential to supply large quantities of
endochondral cancellous bone for reconstruction of large alveolar
defects.10 However, many authors report significant
donor site morbidity, thus leading to the search for alternative
intra-oral donor sites that have easy accessibility, rapid harvesting
time and a low donor site morbidity.11 In line with
this, intramembranous bone grafts from the mental symphysis and
mandibular ramus have been used, albeit sparingly.5Even though endochondral bone grafts remain more popular than
intramembranous grafts, literature reveals endochondral grafts take a
far longer time to achieve complete osseointegration and may undergo up
to 65% volume loss post-operatively. In comparison, intramembranous
bone grafts have shown promising results with rapid healing,
revascularization and negligible bone loss.12
The maxillary tuberosity is recognized as an alternative intra-oral
donor site, however its use has been limited to minor maxillary and
mandibular alveolar ridge augmentation prior to fabrication of
prosthesis and sub antral augmentation.13 Bone from
this region and other intra-oral donor sites develop by intramembranous
ossification, similar to the mode of ossification of the alveolar ridge.
Indeed, studies on animal subjects show rapid osseointegration and
healing when ‘like is replaced with like’.14 A paucity
of information exists regarding the use of bone from the maxillary
tuberosity in reconstruction of bilateral alveolar clefts secondary to
cleft lip and palate. Additionally, the possibility of odontectomy
(disimpaction) sites of the 3rd molars being a donor
site for ABG has not been discussed previously. In this paper, we report
the management of a 14 year old female presenting with bilateral cleft
lip and palate by a combination of orthodontic treatment and surgical
reconstruction of the alveolar ridge using bone harvested both from the
maxillary tuberosity and odontectomy sites of the 3rdmolars.