Alveolar Cleft Grafting
Cleft palate and cleft lip are birth defects that cause facial deformities. The defects occur early in prenatal life, when the sides of the lip and the roof of the mouth in a developing fetus do not fuse together as they should. Clefts can be complete or partial and can occur on one side of the face or on both.
Both cleft palate and cleft lip create serious functional and aesthetic problems in the mouth, nose and face that often require surgical correction. A cleft palate causes a hole in the hard palate (the bony ridge at the roof of the mouth) and/or the soft palate (the muscle tissue farther back in the roof of the mouth), thus affecting a toddler’s ability to develop normal speech and possibly affecting an infant’s ability to nurse. This should be corrected before the age of 2, as speech development is known to occur between 1 and 2 years of age. A cleft lip leaves the top lip unfused. The resulting appearance may range from a small notch in the skin to a complete separation from the lip to the nose. It is often addressed surgically within the first few months of life, to improve the child’s nursing ability.
The bone supporting the teeth of the upper jaw is called the alveolus. Depending on the severity of the cleft, either a cleft palate or a cleft lip can also cause a disturbance in the alveolus – leaving a hole or gap in the bone and gum line. This gap is called an alveolar cleft. An alveolar cleft often creates an opening (called a fistula) between the mouth and the nose. The cleft and fistula often allow reflux of fluids between the two spaces and prevent the proper growth of some of the front teeth, as there is not enough bone to receive the developing teeth. Correction of an alveolar cleft is usually performed around the age of 8 or 9, since correcting it at this age allows time for the face to normally grow and teeth to be moved into the grafted cleft site to develop sufficient root structure. An alveolar cleft is corrected with a graft of bone usually harvested from the patient’s hip.
Goals of alveolar grafting include:
- Closing the fistula
- Providing bone continuity into which the developing adult teeth can erupt
- Building support for the lateral aspect of the nose
Often, before alveolar cleft grafting surgery can be done, the mouth must be widened with an orthodontic brace for several months. Surgery is then done to close the cleft.
The surgery is performed under general anesthesia and very often requires a night’s stay in the hospital. First, bone is taken from another part of the patient’s body (often from the hip or shin). The soft gum tissue is lifted, and the new bone is then grafted to the existing bone in the patient’s upper jaw. The gum is then replaced, and the incision is sewn closed.
Over the next weeks or months, the grafted bone becomes incorporated into the patient’s own bone tissue. Gradually, normal permanent teeth will be able to erupt through the graft. Most often, after all the permanent teeth have erupted, patients will need to return to orthodontics to straighten the teeth.
After surgery, there will be stitches on the gums. These stitches may be covered with a gummy substance. Your child may have some red drainage from the nose and mouth. The lips may be swollen.
Take care to avoid letting the child place hard objects in his or her mouth. A mild saltwater rinse should be used after each meal. Avoid trauma in the gum area. Avoid brushing the gum area until advised by the physician.
The hip incision will have Steri-Strips™ over it, which should be left in place. If the edges of these strips begin to curl up, they may be trimmed. Walking and deep-breathing exercises are strongly encouraged shortly after surgery.
By the time your child is ready to go home from the hospital, he or she should not be experiencing much discomfort. There may be some pain of the hip, if this is where the bone was taken from. Walking and deep breathing are encouraged for this. The physician may suggest pain relief medication if needed. Tylenol™ alone should be tried first. If Tylenol™ with codeine is needed, give it with food as it can cause stomach upset. Limit physical activity (running and hard playing) for the first eight weeks. Once the doctor gives you clearance, you may advance your child’s physical activity and diet.
Risks & Side Effects
Any surgery carries a small risk of infection or bleeding. Every anesthetic also carries a risk, but this is very small. Your child’s anesthesiologist is a board-certified, pediatric-fellowship-trained anesthesiologist, trained to deal with any complications. The surgeon and anesthesiologist will discuss potential risks with you before the operation. Your child may have a headache, a sore throat or a dizzy feeling afterward. These side effects are usually short-lived and not severe.
There is a chance that the graft might not take, in which case it would need to be repeated. This may be due to poor oral hygiene, excessive scarring or just bad luck. Grafts are sometimes damaged by being knocked, so we advise your child to take things carefully for the first six weeks after the operation. Very rarely, the fistula can reopen. This would need to be repaired and might require a second operation.
Watch for and call us if your child exhibits the following:
- Pain, for which pain relief medication does not seem to help
- Signs of infection – either the leg, hip or mouth is red, sore or oozing
- High temperature
- Failure to eat, drink or produce any urine