Secondary Bone Grafting of Alveolar Clefts: A Surgical/Orthodontic Treatment Enabling a Non-prosthodontic Rehabilitation in Cleft Lip and Palate Patients

A procedure combining grafting of cancellous bone to the residual cleft of the primary palate with subsequent orthodontic movement of teeth into the former cleft area is described. The preliminary results from the first 80 patients (89 clefts) are presented. The age of the patients at the bone grafting ranged from 8 to 18 years, and the observation time from 17 to 44 months. The results have been assessed 1) on the basis of dental radiographs and 2) clinically, by the response of the grafted area to the orthodontic movement of adjacent teeth. In 69 clefts in which the cleft side canine had been brought into its final position at the time of evaluation, the height of the interal-veolar septum was assessed to be approximately normal in 38% and slightly less than normal in 44%. A septum of insufficient height (less than 3/4 of the normal) had formed in 5 clefts (7%). Even in these cases, the main objects of the operation were fulfilled: The maxillary segments were stabilized, the teeth adjacent to the cleft had better bone support, and the gap in the dental arch could be closed orthodontically in four of the five clefts. Failures, i.e. no continuous bone bridge across the alveolar cleft, were recorded in 8 instances (9%) of the total material. When failures were disregarded, the gap in the dental arch was closed orthodontically in 90%, while prosthodontic closure was deemed necessary in 10% of the cases. Optimal results were obtained when bone grafting was performed prior to the full eruption of the cleft side canine. In this situation, the known potential of an erupting tooth to induce alveolar bone generation proved to be of great advantage. By deliberately guiding the erupting canine through the grafted area close to the incisor, a nearly normal interalveolar septum was formed, and the gap in the dental arch was closed orthodontically in 23 out of 26 clefts. When fissural teeth were present, they were in most cases integrated in the dental arch. Approximate incisor symmetry could thus be obtained. In the remaining 20 clefts, the ipsilateral canine had not reached its final position at the time of evaluation, and the end results could not be assessed. However, bone formation in the defect was good in 19 of the 20 clefts, and a fully satisfactory result is expected in the majority of these cases. Further advantages were obtained by this procedure: 1) The maxillary segments were stabilized, particularly important in bilateral clefts in which the premaxilla was movable. 2) Oronasal fistulae were effectively closed and mucosal recesses eliminated. 3) The grafted bone provided support for the receded alar base, reducing the nasal asymmetry and improving the facial contour. 4) The postoperative orthodontic treatment could be brought to an end at approximately the same age as for patients with a non-cleft malocclusion. The only significant complication in this series was infection of the grafted area, causing loss of the bone grafts in two cases, and possibly contributing to the failure in some other patients. The experience gained with this treatment permits the conclusion that a full osseous and dental rehabilitation can be achieved in the great majority of patients with cleft lip and palate without any prosthodontic reconstructive work.     

不同术式的双侧牙槽嵴裂植骨术对唇、颊龈沟深度的影响

目的　研究不同术式的双侧牙槽突裂植骨术对唇、颊龈沟深度的影响。方法　对我科 1992年 4月至 2 0 0 2年 3月间采用 :①提袋手柄式瓣牙槽突裂修复术 ;②双颊瓣牙槽突裂修复术 ;③双颊瓣加鼻中隔犁骨凿断牙槽突裂修复的 4 2例牙槽突裂患者进行分析。结果　将术后唇颊龈沟变浅分为Ⅳ级 ,结果 4 2例中 ,0级 2 0例 ,占 4 7 6 % ;Ⅰ级 10例 ,占 2 3 8% ;Ⅱ级 10例 ,占 2 3 8% ;Ⅲ级2例 ,占 4 7%。采用提袋手柄式瓣和双颊瓣加犁骨凿断牙槽突裂修复术的 6例中 ,唇颊龈沟变浅 2 3者有 4例 ,唇颊龈沟消失者 2例 ,可见这两种术式均可使唇颊龈沟变浅。结论　三种术式均有使唇颊龈沟变浅之可能 ,术中应注意预防之     

单侧完全性唇腭裂患者自体骨移植修复牙槽突裂后早期牙移入的CT评价

目的 应用螺旋CT评价早期移动裂隙两侧的牙齿给予植骨区适当的功能刺激能否减少牙槽突裂植骨术后植入骨的吸收,增加新骨的形成,从而提高植骨手术成功率及植骨效果.方法 牙槽突裂患者12例,年龄9～13岁,分为两组：正畸牙移动组（A组）,在牙槽突裂植骨术后早期进行正畸牙移动;对照组（B组）只是行自体骨牙槽突裂植骨术.在植骨前后和正畸治疗后进行三维CT扫描,并对获得数据进行重建分析,观察正畸牙移入植骨区域后,正畸牙位置及牙槽骨的形态及体积变化.结果 两组在术前裂隙宽度及牙槽突裂体积均未见明显差异.术后6个月A组的新骨成骨体积为（0.98±0.23） mm3,显著大于B组的（0.73±0.15） mm3.新骨形成率在A组为（72.5±11.9）％,显著大于B组的（53.2±9.7）％.牙槽突裂患者自体骨植骨术后,早期正畸牙移动可顺利使裂隙侧牙齿移入植骨区域,正畸牙的牙根尖位置发生明显的位移,CT断面未见明显牙根吸收.结论 早期正畸牙移动可明显减少牙槽突裂植骨术后植入骨的吸收,其对植入骨的改建有明显的积极作用.     

Primary,Early Bone Grafting in Complete Clefts of the Lip and Palate: A Follow-up Study of 53 Cases

Fifty-three patients with complete unilateral and bilateral cleft lip and palate between the ages of 5 1/2 and 13 1/2 years have been followed up. Following preoperative jaw orthopedic treatment, when indicated, these cases were operated with lip closure and bone grafting with four mucoperiosteal flaps as described by Nordin (1960) and Bäckdahl & Nordin (1961). In the 14 bilateral cases this operation was done in two stages, one side at a time, in this series. At the follow-up, facial appearance, hearing, speech assessment, some facial angles and incidence of crossbites were examined. In the 39 unilateral cleft cases, 80% had an acceptable appearance while 20% needed secondary surgery of the lip and nose as rated independently by four doctors. In the 14 bilateral cases 50% needed secondary operation of the lip and nose. Speech assessment in the bone-grafted group was good or superior to that in a non-bone-grafted group of patients with clefts of the primary and the secondary palate. Open nasality and consonant articulations were also taken into consideration. No permanent hearing impairment was noted in these patients although they are prone to chronic ear diseases. No serious maldevelopment of the facial skeleton was noted in our study following primary, early bone grafting. The incidence of crossbite was comparatively low. This type of treatment is continuing at our centre since the results are promising. Comparison of similar studies from other centres with long-term follow-ups are called for.     

Maxillary bone transportation in alveolar cleft-transport distraction osteogenesis for treatment of alveolar cleft repair.

Secondary autogenous cancellous bone grafting is a widely used method for the treatment of alveolar clefts and oronasal fistulae. However, failure of iliac bone grafting sometimes occurs due to inadequate covering with the surrounding soft tissue and marked scar formation, inappropriate patient age, or large clefts. For alveolar clefts, we developed a method consisting of alveolar bone transportation, closure of the alveolar cleft, and/or grafting of new bone. Transport distraction osteogenesis along the curve of the dental arch is ideal. Alveolar bone was transported in the planned direction using a ready-made bone-borne distractor in combination with an orthodontic arch wire for transport guidance. This method allows simultaneous correction of nasal septal deviation and also correction of maxillary arch deformities and malocclusion since, the dental arch is expanded without donor sacrifice. This method can be regarded as tissue engineering to expand bone tissue. This method can be safely performed not only in patients undergoing initial treatment for alveolar clefts but also in patients in whom bone grafting has failed. Since 1997, we have performed this method in 22 patients and obtained good results.     

The use of free-periosteum for secondary bone grafting to the maxillary alveolar clefts

Some modification on the surgical technique for bone grafting to the alveolar clefts has been required. Secondary bone grafting was performed with and without free-periosteum on 34 (mean age, 9.8 +/- 1.1 years) and 44 (mean age, 10.7 +/- 1.2 years) alveolar clefts, respectively. Vertical bone formation which scored 3 or 4 was obtained in 97.1% of free-periosteum grafted clefts, while it was obtained in 79.5% of the control group. The rate of postoperative wound dehiscence in free-periosteum grafted clefts (20.6%) was not significantly different from the control group (11.4%). In the wound dehiscence cases, however, the grafted periosteum covered the grafted bone and prevented bone exposure. The score of bone formation in the free-periosteum grafted clefts (3.57 +/- 0.79) was significantly higher than that of the control group (2.60 +/- 1.34). Thus, free-periosteum grafting in secondary bone grafting is useful for bone formation in alveolar clefts.     

Early bone grafting in complete cleft lip and palate cases following maxillofacial orthopedics. IV. A radiographic study of the incorporation of the bone grafts

The development of bone grafts in complete alveolar clefts was studied with standard radiographic methods. The patients were divided into three groups: one unilateral group of 39 children operated on between 1960-1965 without preoperative orthopedics, another unilateral group of 46 children operated on between 1965-1972 after preoperative orthopedics ("T-traction") and one group of bilateral clefts with 19 children operated on 1960-1972 after premaxillary retropositioning pressure if necessary combined with outward rotation of the lateral segments. All children had bone grafts inserted with "a four-flap" technique. The results were compared with those operated on with early bone grafting by a different method. The results were similar with good healing and incorporation of the transplanted bone. The group bone grafted after preoperative "T-traction", which facilitates the surgical procedure, showed the highest alveolar bone level. The amount of bone seemed to increase with increasing age of the patient and migration of teeth into the grafted region.     

Assessment of secondary alveolar bone grafting using a modification of the Bergland grading system.

Although the management of the alveolar cleft remains controversial secondary alveolar bone grafting is the most widely accepted approach. The results of a series of 71 secondary alveolar bone grafts performed between 1990 and 2001 on 58 patients with complete cleft lip and palate 13 of which were bilateral are presented. Bone grafts were assessed when the canine tooth had fully erupted using periapical dental radiographs.The occlusal level of the newly obtained interdental bone of each grafted cleft was recorded and categorised in accordance with the Oslo grading system as described by Bergland. In addition the basal level of each bone graft was recorded. In this way total bone graft height was measured and each graft was categorised with respect to the desired normal height of noncleft interdental alveolar bone. This modified analysis grades more precisely the efficacy of secondary alveolar bone grafting and helps to identify and categorise those patients with insufficient bone for dental, orthodontic and orthognathic rehabilitation and those who may require further investigation and regrafting.     

New orthodontic and orthopaedic managements on the premaxillary deformities in patients with bilateral cleft before alveolar bone grafting

At the age of mixed dentition, a downward or laterally displaced premaxilla with a wide alveolar cleft in patients with bilateral cleft lip and palate remains a dilemma both for orthodontists and surgeons. These premaxillary deformities not only make the alveolar bone grafting difficult but also aesthetically and functionally unacceptable. The purpose of the present article is to introduce three new orthodontic and orthopaedic techniques for solving these premaxillary deformities and facilitating alveolar bone graft through a non‐surgical approach. These techniques are the premaxillary orthopaedic intrusion for correcting a downward displaced premaxilla, the premaxillary orthopaedic repositioning for correcting a laterally displaced premaxilla, and maxillary orthopaedic protraction by alternate rapid maxillary expansions and constrictions for minimizing a wide alveolar cleft. They were evaluated clinically and cephalometrically for their treatment effects. The results revealed that the premaxillary and cleft deformities were corrected in a short period of time and therefore the alveolar bone grafting could be carried out without difficulty in all of the patients who received the treatment. The treatment effects were mostly orthopaedic and partly orthodontic. No growth disturbance on the maxilla was observed throughout the treatment. These new orthodontic and orthopaedic techniques are very effective for solving the difficult‐to‐treat premaxillary deformities and facilitating the alveolar bone grafting in the patients with bilateral cleft.      

Early bone grafting in complete cleft lip and palate cases following maxillofacial orthopedics. II. The soft tissue development from seven to thirteen years of age

The subsequent effect of preoperative maxillofacial orthopedics and early bone grafting on the development of the soft tissue profile of the face was studied with roentgencephalometric analysis on cleft patients between 7 and 13 years of age. They were divided into two unilateral and one bilateral complete-cleft group, all having been bone grafted early with the "four-flap" technique. The two unilateral groups were one group of 39 children operated on between 1960 and 1965 without preoperative orthopedics and one group of 46 children operated on between 1965 and 1972 after preoperative orthopedics ("T-traction"). The bilateral group comprised 19 children operated on between 1960 and 1972 after premaxillary retropositioning pressure, combined when necessary, with outward rotation of the lateral maxillary segments. Comparisons of facial growth were made with U.S. non-grafted clefts and with nonclefts. The effect of the preoperative orthopedic management facilitated the subsequent surgical procedure by a narrowing of the cleft and replacement of the deviated maxillary and nasal structures. The results were within limits of the non-grafted cases, with the exception of the soft tissue overlying the subnasal region. The reduced prominence of that region was explained by the primary surgical procedure, which made the lip adherent to the alveolar crest. In comparison with nonclefts, all parameters indicated a reduced growth capacity.     

Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16-19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16-19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16-19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

A Follow-Up Study of Cleft Children Treated with Primary Bone Grafting: I. Orthodontic Aspects

The effect of primary bone grafting in the treatment of complete clefts has been studied with roentgenologic and biometric methods. The material, operated on during 1958–64, consisted of 16 patients with complete bilateral cleft lip and palate and 37 cases with complete unilateral cleft lip and palate. All of the studied bone grafts (= 69) healed well, but this did not lead to the expected normalisation of the growth of the middle face. On the contrary, our patients developed a pronounced maxillary retrognathia, which seemed to increase with age. This resulted in a concave facial skeletal profile for both the bilateral and unilateral cases. The occlusal analysis also indicated a maxillary growth retardation. Thus, our patients revealed a much higher frequency of anterior as well as lateral crossbites, when compared with other studies on not-bone-grafted clefts. Also, our patients had increased frequency of Class III molar relations while fewer had Class I and Class II relations. The growth aberration in many cases reached such a degree that the primary bone grafting of further cleft patients was discontinued.     

Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract

This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16–19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16–19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16–19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

自体髂骨复合PRF修复牙槽嵴裂的实验研究

目的:将富血小板纤维蛋白(Pl at el et-ri ch fi bri n,PRF)应用于牙槽嵴裂植骨手术,验证其是否能够减少植骨术后的骨吸收。方法:8～12月龄犬8只,以外科手术的方法制备双侧牙槽嵴裂模型,随机于两侧同期植入自体髂骨(对照组)及自体髂骨混合PRF(实验组)。于术后当日、2个月、4个月时拍摄上颌骨CT,利用三维重建软件测量植骨区体积,计算骨吸收率。结果:术后2个月、4个月时实验组的骨吸收率明显小于对照组,行配对样本的t检验,P<0.01。结论:将PRF加入自体髂骨进行骨移植修复犬的牙槽嵴裂,在术后4个月的时间范围内,可以减少术后的骨吸收。     

Secondary alveolar bone grafting: An outcome analysis

OBJECTIVE

To review the outcome of secondary alveolar bone grafting in unilateral and bilateral cleft lip and palate.

DESIGN

A surgeon’s experience, by retrospective chart review, of 70 consecutive patients at a tertiary care centre.

OUTCOME MEASURE

Periapical radiographs were taken at least six months after secondary alveolar bone grafting. The Enemark grading system was used to stratify graft-take.

RESULTS

In unilateral clefts, 33% were level 1, 36% were level 2, 20% were level 3 and 11% were level 4. In bilateral clefts, 29% were level 1, 50% were level 2, 14% were level 3 and 7% were level 4. There was no statistically significant difference between the level of take and the type of cleft. Complications encountered were infection (n=3), fistula (n=3), pain (n=4) and bone graft exposure that led to failure (n=2). Two patients required reoperation for bone grafting.

CONCLUSIONS

The iliac crest is a good donor site with excellent results and minimal morbidity.     

33例颅面裂Tessier分类诊断与治疗体会

目的介绍颅面裂的Tessier分类诊断与手术治疗体会。方法按Tessier分类法对33例颅面裂患者进行分类，并根据畸形类型及轻重程度制定手术方案；共施术29例，手术方法包括单纯眶内侧壁截骨与鼻翼软骨修整、局部皮瓣转移、内眦固定、真皮移植、骨移植、组织代用品置入、吻合血管的游离组织瓣移植等。结果33例中属0号颅面裂1例、0—14号颅面裂3例、1号颅面裂1例、2-12号颅面裂2例、3号颅面裂3例、4号颅面裂1例、5／6号复合颅面裂1例、7号颅面裂18例、6／7／8号复合颅面裂2例、11号颅面裂1例；29例接受手术的患者，术后面部形态明显改善，无并发症发生。结论①Tessier颅面裂分类法有助于发现与主诉体征相伴的其它颅面畸形，对作出全面正确的诊断及制定手术方案具有重要的指导作用。②在Tessier颅面裂中以7号颅面裂较为常见。③Tessier颅面裂有不同的类型，且每一类型的颅面裂又有不同的严重程度，而且不同类型及不同严重程度的颅面裂又可见于同一患者，需根据患者具体情况制定个性化的手术方案。     

Reconstruction of Previously Failed Alveolar Bone Grafts with Medial Femoral Condyle Flap in Pediatric Cleft Lip and Palate Patients

Alveolar cleft reconstruction is important to increase the quality of life of cleft lip and palate patients. Usually, alveolar clefts can be reconstructed using bone grafts. However, bone grafting can be insufficient, and other alternatives may be necessary in wide and recalcitrant clefts. The medial femoral condyle (MFC) flap may be the solution for alveolar clefts that are impossible to reconstruct with bone grafting. In this study, the reconstruction of alveolar clefts in the pediatric cleft lip and palate population, using the MFC flap, is described.This study examined 9 pediatric patients whose alveolar clefts were reconstructed prospectively using MFC flap in 2015 and 2019. The age, gender, follow-up times, independent parameters, and existence of concomitant vestibulonasal fistulas of the patients were recorded. Computerized tomography images of the patients were evaluated to detect defect characteristics and evaluate the volume of flap postoperatively. Flap viability was confirmed with bone scintigraphy, and donor area morbidity was evaluated with the Dynamic Gait Index (DGI) in the postoperative period.The study included 7 male and 2 female patients. The mean age of the patients was 13. In addition to an alveolar cleft, 6 patients also had vestibulonasal fistula. It was observed that the volume of the flaps had not changed one year after the operation. The DGI score of all the patients was 24.Existing techniques may be inadequate in the reconstruction of wide and recalcitrant alveolar clefts. MFC flap may be the start of a new era for the treatment of alveolar clefts.     

Dentofacial relations in young adults with unilateral complete cleft lip and palate. A follow-up study

A retrospective study was made on 30 patients born between 1958 and 1969 with unilateral complete cleft lip and palate (C-UCLP) and operated on at the Department of Plastic Surgery, University Hospital, Ume?, Sweden. All patients were operated on by the same surgeon. The results are based on data from records at 5, 10, 16 and 20 years of age. The facial morphology of the cleft children at 5 years of age was rather close to that of the normal children. During growth the faces became retrognathic, more visibly so in the maxilla resulting in straight or concave profiles. This was more evident among the boys. There were no differences regarding maxillary growth between children bone grafted at 10 to 16 years of age and those bone grafted after 16 years of age or not at all. Although surgical procedures and orthodontic treatment varied, 70% had less than 3 teeth in crossbite relationships at 20 years of age. An important factor to take into consideration is the fact that in addition to the influence that the cleft morphology and treatment have on the dentofacial growth, other dentofacial growth patterns also exist among the cleft patients. Generally the groups of patients reported are rather small and therefore conditions like these can have a strong influence on the results.     

Alveolar bone grafting in association with polyostotic fibrous dysplasia and bisphosphonate-induced abnormal bone turnover in a bilateral cleft lip and palate patient: a case report

A case is presented of extensive alveolar bone grafting in a patient with bilateral cleft lip and palate and polyostotic fibrous dysplasia. The patient previously underwent bisphosphonate therapy. Because of an abnormal and often decreased bone turnover caused by the fibrous dysplasia and the bisphosphonate therapy, bone grafting in such a patient poses several potential difficulties. In addition, the histomorphometric analysis of the bone grafts showed markedly decreased bone turnover. However, alveolar bone grafting using the iliac crest was performed successfully. Sufficient occlusion was achieved by postoperative low-loading orthodontic treatment.     

A Follow-Up Study of Cleft Lip and Palate Patients Treated with Orthodontics,Secondary Bone Grafting,and Prosthetic Rehabilitation

The purpose of this study was to evaluate the significance of secondary bone grafting in cleft palate treatment. The investigation included a clinical, a biometrical, and a radiographic follow-up of the occlusion, the craniofacial morphology and the function of the masticatory system. The total material of secondary bone grafting cases during the period of 1958–68 consisted of 125 patients. For the final examination, 93 of them were present. The treatment plan was: (1) orthodontic treatment, (2) bone grafting, (3) retention treatment, (4) prosthetic reconstruction of lost teeth. 58 bridges were inserted. The mean age of the patients at the time of bone grafting was 20 years and the mean lag between the bone grafting procedure and the final check-up was 7 1/2 years. Besides bone grafting, 43 palatopharyngeal flap-operations were carried out. At the final check-up, none of the patients wear any obturator. Besides these operations 7 osteotomies of the lower jaw were carried out. The frequence of crossbites was reduced from 94 to 31%. Open bites were present in 6 cases while the remaining cases exhibited normal overjet and overbite. A slight degree of relapse after the orthodontic expansion treatment was noted; thus, in 12 cases, one or two teeth relapsed to crossbite occlusion. The jaw function was fairly normal in all cases studied. The chewing ability was reduced in 9 cases, though the average number of tooth contact-pairs increased, from 5.9 prior to orthodontic treatment to 11.4 at the final examination. The cephalometric part of the investigation indicated that the average patient had a more retrognathic type of face with steeper mandibular and nasal planes than are reported for non-clefts. The bone grafting procedure was successful in 96% of the cases, as evaluated from radiographs. The reorganisation of the average bone graft was completed within 3 to 6 months. This clinical and radiographic investigation revealed that bone grafting of the alveolar process and the palate did normalise and stabilize the maxilla in practically all instances. Thus the method used had prevented relapse after orthodontic treatment in the great majority of cases and the definitive prosthetic rehabilitation could be carried out using the same principles as in non-cleft cases.