Effect of timing on long-term clinical success of alveolar cleft bone grafts

Despite the almost universal agreement on the desirability of bone grafting in the cleft alveolar process, there are little long-term data to support preference for grafting at one time versus another. Investigation was undertaken to compare the clinical success of grafts placed at three distinct developmental stages: the "primary" group consisting of 20 rib grafts placed at less than 1 year of age; the "secondary" group consisting of 19 iliac crest grafts placed when the permanent canine was one fourth to one half formed; and the "delayed" group consisting of 18 iliac crest grafts placed after eruption of the permanent canines. Patients were a minimum of 15 years of age at time of final evaluation. Records were made a minimum of 5 years postsurgery. Biometric data and periapical x-ray films were evaluated. There was a trend for the delayed group to have a decreased incidence of successful bony bridging of the graft site compared with the other treatment groups. The primary group exhibited significantly (P < 0.001) greater ridge height and increased bone attachment than the secondary and delayed groups. There were significantly fewer teeth lost adjacent to the cleft for the primary group compared with the secondary and delayed groups. Before orthodontic treatment, there were no significant differences among groups in incidence of anterior crossbite; posterior crossbites were seen more frequently in the secondary and delayed graft groups than in the primary group (P < 0.001). At final evaluation, there were significantly fewer anterior and posterior crossbites in the primary group than in the secondary and delayed groups (P < 0.002). Incidence of regrafting was significantly less (P < 0.05) for primary versus secondary and delayed groups. Overall results suggest the primary graft group was equal or superior to secondary and delayed groups in all respects; approximately equal success was achieved in the secondary and delayed groups.