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.