September 2019 HSC Section 1 Congenital and Pediatric Problems

Gingivoperiosteoplasty and Alveolar Bone Grafting

independently induce bone formation, 32 although the oncogenic potential and severe inflammatory response in select populations remains unknown therefore limiting its widespread use. BMP does not have Food and Drug Administration approval for the age group most likely to undergo alveolar cleft grafting because of possibilities of uncertain effects on the immature skeleton, influence on developing dentition, or role in malignant tumor formation. 33 Currently BMP may play a role in the skeletally mature patient but is not approved for use in the typical skeletally immature cleft patient. Complications The most common complication after alveolar cleft grafting is mucosal wound dehiscence, which occurs in 1% of prepubertal children 34 and this percentage increases with age. 35 This may lead to a persistent fistula. In general, with good surgi- cal technique and appropriate timing wound breakdown should be rare. Graft loss that requires repeat grafting is also unusual, although more common in the adolescent and young adult. Finally, failure of canine eruption through the grafted alveolus may require surgical exposure and ligation in approximately 1% of cases. 34 SUMMARY Appropriate selection, evaluation, management, preparation, and education done by a multidisci- plinary team are all essential when caring for a patient with orofacial clefting. Associated congen- ital anomalies, developmental delay, neurologic conditions, and psychological needs must be recognized and addressed. Because of morpho- logic variability of various cleft types there are several options for the surgical team to choose from as previously described. Despite the tech- nique used, a multilayer, tension-free closure with velar sling restoration remains the fundamental goal of surgical correction. Presence of an alveolar cleft offers an additional challenge with various management and treatment options. GPP remains controversial and has the attraction of an inductive surgical procedure that provides an opportunity for improving form and function early in life while potentially sparing additional surgery, although the concern of iatrogenic facial growth restriction remains. Alveolar bone grafting also has several considerations including timing, material used, consideration of dentition, and the use of presurgi- cal expansion devices. Overall there are amultitude of factors to consider and decisions tomake, which requires a large team of approach when providing care to patients with orofacial clefting.

REFERENCES

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