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.

Alveolar bone grafting

Objectives: Guided bone regeneration with alloplastic bone graft substitutes has a high impact in surgical dentistry nowadays. In the future, the orthodontist will inevitably be confronted with patients with such a medical history. A review of the literature was performed to investigate present materials used, indications, and concerns and problems in interdisciplinary treatment of patients with nonautogenous bone grafts. Method and Materials: An electronic key word search in the literature database PubMed of the US National Library of Medicine and The Cochrane Library (CENTRAL) of the Cochrane Collaboration was performed. Numerous journals were searched manually, and the reference lists of all identified papers related to the topic were reviewed to warrant completeness. All abstracts of the identified publications were screened in duplicate by two autonomous reviewers. Inclusion criteria were the use of a nonautogenous bone graft followed by orthodontic tooth movement or a tooth eruption through the grafting material. Results: The total number of identified publications was 37. It was possible to divide these into two major topics, orthodontic tooth movement in bone graft and tooth eruption through bone graft. Besides experimental setups, indications were periodontal defects, cystic lesions, and alveolar clefts. Here, different types of bone graft were used. The following tooth movement was partially uneventful and sometimes attended by serious adverse effects. The resulting articles presented a low level of evidence and showed diversity in question, methodology, and type of publication. For this reason, it was not possible to perform a quantifying review. Therefore, the articles are discussed in a descriptive manner with regard to the topic in question. Conclusion: Both orthodontic tooth movement and tooth eruption through grafted bone are not only possible but also might provide promising results. However, more research on this interdisciplinary treatment is necessary to avoid risks and achieve more safety in orthodontic treatment of these patients.

The impact of nonautogenous bone graft on orthodontic treatment.

Despite increasing interest in age- and gender-related bone alterations, data on trabecular microstructure at the proximal tibia are scarce. The aim of this study was to identify trabecular microstructural change at the human proximal tibia with age and gender, using micro-computed tomography (micro-CT) and scanning electron microscopy (SEM). Fifty-six proximal tibias from 28 Japanese men and women (57-98 years of age) were used in this study. The subjects were chosen to give an even age and gender distribution. Both women and men were divided into three age groups, middle (57-68 years), old (72-82 years) and elderly (87-98 years) groups. The trabecular bone specimens from the medial compartment of the proximal tibial metaphysis were examined. Trabecular bone mineral density (BMD), bone volume fraction (BV/TV) and trabecular thickness (Tb.Th) decreased between the middle-aged and elderly groups similarly in women and men. However, trabecular number (Tb.N) decreased by 13% between the middle-aged and elderly groups in women and nearly double that in men. As compared with women, men had higher BV/TV and lower trabecular separation (Tb.Sp) in the old age and elderly groups, and higher Tb.N and connectivity density (Conn.D) in the elderly group. Increased trabecular resorbing surfaces, perforated or disconnected trabeculae and microcallus formations were observed with age. These findings indicate that both BMD and BV/TV decreased at the proximal tibia with age similarly for women and men, but significant differences between women and men were observed for some microstructural parameters. These findings illustrate potential mechanisms underlying osteoporotic proximal tibial fracture.

/pdf/gender-related-changes-in-three-dimensional-microstructure-4qq02uabq7.pdf

Gender-related changes in three-dimensional microstructure of trabecular bone at the human proximal tibia with aging.

Autogenous bone grafting is the gold-standard technique for bone augmentation procedures prior to implant placement. If the amount of available intraoral donor bone is insufficient, it is necessary to harvest bone graft from extraoral sites, such as calvaria. Although this technique is well established, only a few case reports show the histological analysis of the grafted bone at the moment of implant placement. This article reports the case of a 48-year-old female patient with a critical atrophic maxillary ridge reconstructed using autogenous calvarial bone graft prior to implant placement, with clinical and histological evaluation. Bone was collected under general anesthesia from the parietal bone. The outer cortical originated the bone blocks, and the medullar bone layer between was collected to be used in the sinus augmentation procedure, together with 5 of the bone blocks triturated. Six months after bone augmentation, 8 implants were placed in the grafted area and 2 biopsies were retrieved (anterior...

Calvarial Autogenous Bone Graft for Maxillary Ridge and Sinus Reconstruction for Rehabilitation With Dental Implants

In this study, radiographic assessment was performed to find out the effectiveness of bone regeneration following the application of recombinant human bone morphogenetic protein 7 (rhBMP-7) for the reconstruction of alveolar cleft defects in 11 cases: nine unilateral and two bilateral alveolar clefs. Reconstruction of the alveolar cleft was performed by using 3.5 mg of rhBMP-7 (Osigraft OP1) on a type I collagen carrier. Radiographs were taken 6 months post operation using a Gendex Intraoral Unit with Agfa Dentus M2 Comfort occlusal film. The amount of bony infill was graded on a Kindelan four-point scale. The patients were followed up for an average of 6.6 years. Based on the radiographic analysis, eight out of the nine unilateral alveolar cleft cases received a score of grade I and one patient had a grade II score, using the Kindelan scale. In the two bilateral alveolar clefts, only one side had bone formation. The radiographic appearance showed a normal trabecular pattern similar to the adjacent bone. Thus, rhBMP-7 was radiographically and clinically successful in regenerating the bone at the alveolar cleft which resulted in shortening of the operation time, absence of donor-site morbidity and a shorter hospital stay. The promising results of this preliminary study should encourage a phase II trial to compare bone grafts with BMP for the reconstruction of alveolar defects.

https://www.jprasurg.com/article/S1748-6815(15)00437-4/pdf

The clinical application of rhBMP-7 for the reconstruction of alveolar cleft.

Donor site morbidity is important in deciding the site for harvest of cancellous bone for alveolar bone grafts. Many studies have supported the view that tibia is safe with few complications in the short term. We know of no studies on the long-term complications to the donor site after tibial bone grafting in children with alveolar clefts. The casenotes of 40 children who had had tibial bone grafts for alveolar clefts were studied retrospectively, and parents or patients were contacted by telephone and a standardised questionnaire was used to assess any long term complications at the donor site. We found none. We found no evidence of long-term complications at the donor site in children who had had proximal tibial bone grafting for secondary repair of alveolar clefts. We conclude that the proximal tibia is a safe site from which to obtain cancellous bone graft for alveolar clefts in children. This study is preliminary, and highlights the need for a randomised trial.

Retrospective review of donor site complications after harvest of cancellous bone from the anteriomedial tibia.

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Retrospective review of donor site complications after harvest of cancellous bone from the anteriomedial tibia.