Combined orthodontic-surgical management of residual palato-alveolar cleft defects.

These cases are presented in detail from a series of fifteen cases treated in the described manner, with follow-up orthodontic documentation 2 to 5 years after PMCB grafts. The long-term results in all of the cases were excellent. Late or secondary bony reconstruction of the osseous alveolar and anterior palatal clefts may be accomplished with either an essentially nonviable autogenous graft or an autogenous particulate marrow and cancellous bone graft. The differences essentially are as follows: 1. In the nonviable graft, orthodontic movement of teeth adjacent to the cleft is undertaken at some time prior to the grafting procedure. This is opposed to the use of the autogenous PMCB graft in which active orthodontic treatment may be undertaken within 2 months after the osseous grafting procedure. 2. In the use of nonviable autogenous bone, presurgical orthopedic treatment to expand the arch is usually essential since extensive arch expansion is not usually possible after grafting. With PMCB grafts , postsurgical arch expansion may be routinely undertaken. 3. It is thought that the use of rib, solid one-piece grafts from the ilium, and other types of nonviable graft is warrented only after major growth and development of the premaxillary region has occurred. This is due to lack of ability of such a grafted area to keep pace with the growth of adjacent bone segments. This would mean that secondary grafting with such grafts would be restricted to patients over 15 years of age. This is opposed to the PMCB technique, in which the next procedure may be undertaken at any time from the age of mixed dentition to adulthood but preferably earlier than the age of 7, before the lateral incisor has erupted and been lost through exfoliation into the cleft area. Thus with these two techniques, there is a marked difference in the philosophy of grafting and a marked difference in the overall results. There is, in addition, an altered philosophical effect upon the total maxillofacial cleft palate team, with a marked difference in the type of treatment and prognosis which can be offered in terms of social rehabilitation of the patient. While the team approcah to the treatment of the cleft palate patient has done much to advance rehabilitation in terms of social and psychological problem areas, speech correction, and soft-palate and cosmetic lip restoration, much needs to be done to rehabilitate the patient completely from a dental standpoint. We believe that the prognosis of dental rehabilitation without appropraite bone-grafting procedures of the alvolar and prepalatal cleft is unfavorable. The use of the PMCB procedure in conjunction with orthondotic therapy opens new avenues to the total rehabilitation of the patient with an anterior maxillary cleft.