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Alveolar bone graft (ABG) at North Austin Campus

Conditions

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Children born with a combined complete cleft lip and palate will have a gap or cleft of the gum line bone behind the cleft lip. We call this an “alveolar (al-vee-OH-lar) cleft”. Children with an isolated cleft lip but no cleft palate can also have an alveolar cleft. If an alveolar cleft is present, we will discuss the importance of a procedure called “alveolar bone graft” or “ABG”. 

ABG is an important surgical step in reconstructing a cleft since it is required to support the health of the adult teeth in the area, and to allow us to give your child a healthy and stable bite into adulthood. 

  • If your child has a wide alveolar cleft, you will easily see it as a missing segment of the gum line behind the cleft lip. 
  • The alveolar cleft is usually wide at birth, but will decrease in size after nasoalveolar molding (NAM) or after a cleft lip repair or cleft lip adhesion.
  • Patients with isolated cleft lip can still have an alveolar cleft, but the gap may not be visible without an x-ray.
  • When an alveolar cleft is present, the gap in the bone is always bigger than the visible gap in the gums
  • Before treatment, the bottom of the alveolar cleft opens up into the mouth and the top into the nose, creating a tunnel that joins the mouth and the nose. We call this an “oro-nasal fistula”.


The alveolar cleft is a gap of bone missing next to the front teeth that runs from the nose into the mouth. 

  • We want to repair an alveolar cleft before the adult tooth on the side of the cleft starts to show.
  • We will recommend a dental x-ray for your child at the age of 5-6 years to see how their teeth are developing and when we expect they will first show through the gums.
  • In almost all clefts, the adult tooth we focus on is the “canine” or “dog tooth”. This is the pointy tooth close to the front teeth. The canine tooth usually shows through the gums between 9 and 13 years, so we perform the ABG surgery between the ages of 7 and 9 years to make sure the bone is ready for the tooth.
  • In 1 out of 10 clefts, the tooth immediately next to the front teeth is big enough to survive. This is the “lateral incisor”. This tooth comes down between 7 and 8 years of age, so in these rare cases we will do the ABG at 5 to 6 years.
  • Our craniofacial orthodontist will let you know if any orthodontic treatment is required to prepare the upper jaw for the graft. Some children will require an orthodontic device called an “arch expander” to line up the gums before surgery. This usually takes 6 months to work.
  • We will schedule your child to have any baby teeth around the cleft removed approximately 2 months before the graft surgery.
  • We will recommend your child have a good dental cleaning by your pediatric dentist a few weeks before surgery.

  • The alveolar bone graft (ABG) surgery usually takes less than 2 hours. In most cases, your child can leave the hospital the same day.

  • Our anesthesiology specialists will do a special nerve block at the beginning of the procedure to manage any pain from the hip after surgery.

  • The surgeon will take the bone graft from the inside of the crest of bone you can feel under the beltline above the hip (the iliac crest). This does not affect the hip joint in any way. The incision to take the bone graft is approximately one inch long

  • Your surgeon will take these small bone chips (“graft”) and place them in a pocket of gum tissue that they will create inside the cleft (Figure 1).

  • In North Austin we can usually repair the hole between your child’s nose and mouth (fistula) at the time of their first cleft lip surgery. We will close the hole if it is still present at the time of ABG surgery.

  • Your surgeon repairs the gum tissues and hip incision with dissolving sutures.

The surgeon opens the lining of the gum and makes a small pocket by closing the hole between the nose and mouth.

Once the nose and mouth lining are closed and the surgeon has created the pocket, they place bone chips from the iliac crest inside. These chips will heal within 6 weeks to create a bridge of bone across the cleft. 

The surgeon finishes the surgery by closing the front of the pocket with dissolving sutures. It is important to keep all sutures clean of food during healing, including the area deep under the lip (arrow)

  • Your child will have cheek swelling on the side of the graft surgery that will be worst the day after, and will last for 3 days before going down. Bruising is uncommon but possible.
  • Although the special nerve block helps with hip graft pain after surgery, we still expect your child to complain of some aching in the hip area and to limp slightly for 3-5 days.
  • Tylenol and ibuprofen will control your child’s pain after surgery. We will give a small number of prescription pain pills to use for 2 to 3 days only if needed.
  • Most children take a week off school after ABG surgery.
  • The bone graft takes 2 months to heal into solid bone. It is important to remember the graft is like a broken bone that needs protection to heal during this time.
  • Since we cannot put a cast to protect your child’s healing bone, they need to protect the graft by using special mouthwash for two weeks, and by not chewing any food during six weeks of healing.
  • Your child cannot play any competitive or contact sports for 6 weeks after surgery.
  • After six weeks, your child can return to normal activities and diet.
  • We will give you detailed information on how to take care of your child after surgery and what types of food they can and cannot eat during healing.
  • Our craniofacial orthodontist will arrange for a dental x-ray to check on the volume of healed bone 6 months after surgery. Healed bone does not usually show up on x-ray before this time. 
  • In some cases, our orthodontist will ask the surgeon to add more bone to the cleft area if there is not enough to support the tooth. This would need an additional surgery. 
  • Your orthodontist will usually wait until more adult teeth have come down after alveolar bone grafting before they start any braces. 
  • The main risk after alveolar bone graft surgery is infection because of the types of bacteria in the mouth.
  • Early signs may be new swelling of the cheek, drainage around the gum stitches, or a bad smell in the mouth.
  • An infection can cause the wound in the gums to open, and the bone to be exposed.
  • It is important to let us know if you have any concerns about the incision in the mouth when you check it each day.
  • We use all the precautions possible to prevent complications after bone graft surgery, but one in every 10 clefts will need a repeat surgery to add more bone to the cleft. This is one of the highest success rates for this surgery.