The alveolus is the part of the upper jaw where your teeth are. Some people with cleft lip and palate can also have a cleft in this part of the jaw. They may also have a hole called a fistula between their nose and mouth. An alveolar bone graft aims to correct the cleft in the jaw and also the fistula, if there is one.
Why might my child need an alveolar bone graft?
Your child may need an alveolar bone graft to allow his or her teeth to develop in the right place. Teeth develop inside the jaw and break through (erupt) the gums when they have nearly developed fully. However, they need to be surrounded by bone to erupt. If a child has a cleft, the teeth near it may erupt in the wrong place or may not erupt at all, in which case false teeth or a bridge may be needed later. The alveolar bone graft allows the teeth to erupt in the right place.
Your child may need a brace to straighten his or her teeth by moving them into the correct position. However, teeth cannot be moved into a cleft as they will become loose and can be damaged. The alveolar bone graft fills the cleft with bone so that the teeth can be moved to fill the gap. Some children still need false teeth or a bridge later on, but they will be smaller and more stable after the graft.
If your child has a fistula, food and fluid can leak into his or her nose from the mouth. The alveolar bone graft seals the fistula so this cannot happen. Air can also leak through the fistula, which can make your child’s speech sound nasal. The graft can also reduce the amount of air leakage, which can improve your child’s speech.
When might my child need the operation?
This depends on how quickly your child’s teeth are developing but normally happens when your child is between eight and ten years of age. A series of X-rays are used to work this out so the operation can be best scheduled to allow your child’s teeth to develop normally.
Preparing for the alveolar bone graft
Some children need a short period of orthodontic treatment using fixed or removable braces before the operation. This takes six months to a year and aims to improve your child’s bite (how the teeth fit together when your child bites on something) and the shape of the cleft. Other children need some baby teeth removed a few months beforehand so that the gum is fully healed by the time of the operation.
What happens before the operation?
Your child will need to come to the hospital one week before the operation for a pre-admission check. At this time, you will have the opportunity to discuss the operation again and any concerns or questions you may have. We will ask you to give your permission for the operation by signing a consent form. We may also ask for some blood samples to check that your child is well before the operation. If your child has any medical problems, like allergies, please tell us. You will be able to discuss the anaesthetic with your clinical nurse specialist.
On admission day
You will need to arrive early on the ward. If this is difficult, we may be able to arrange for you and your child to stay in the patient hotel.
At the pre-admission appointment, the nurses will explain about fasting times for the operation. It is important that your child does not eat or drink anything for a few hours before the anaesthetic. This is called ‘fasting’ or ‘nil by mouth’. Fasting reduces the risk of stomach contents entering the lungs during and after the procedure.
You will be informed the night before the procedure of the time that your child should be ‘nil by mouth’ – in other words, have nothing to eat or drink before the anaesthetic. Fasting times are provided in your admissions letter – in broad terms, this is six hours for food (including milk), four hours for breast feeding and two hours for clear fluids before the procedure.
It is equally important to keep giving your child food and drink until those times to ensure they remain well-hydrated and get adequate nutrition. This may involve waking your child in the night to give them a drink which we recommend.
What does the operation involve?
The operation is in two parts. First, we need to take some bone from either your child’s tibia (shinbone) or hip to put into the cleft. The hip tends to only be used when a larger amount of bone is needed. The tibia is the most common ‘donor’ site. The surgeon will use a ‘window’ so that he or she can remove the small piece of bone and bone marrow used for the graft. The window is then closed and after a few weeks, the bone that has been removed will have re-grown.
The second part of the operation is to repair the alveolar cleft. The surgeon will expose the cleft by making a cut in the gum and then pack the bone into the cleft. The fistula will be stitched closed and the surgeon will finish by stitching the gum over the bone graft to close it.
Are there any risks?
Any surgery carries a small risk of infection or bleeding. Every anaesthetic also carries a risk, but this is very small. Your child’s anaesthetist is an experienced doctor who is trained to deal with any complications. The surgeon and anaesthetist will discuss potential risks with you before the operation. Your child may have a headache, a sore throat or feel dizzy afterwards. These side effects are usually short-lived and not severe.
There is a chance that the graft might not take, in which case it would need to be repeated. This is often due to poor tooth brushing after the operation, so to reduce this chance your child might need to see our dental hygienist before the operation. Grafts are sometimes damaged by being knocked so we advise your child to take things carefully for the first couple of weeks after the operation. Very rarely, the fistula can reopen, which would need to be repaired in a second operation.
If your child has had bone taken from the shinbone, there is a chance that the bone could be weaker than usual and so more likely to fracture. To reduce the risk of this happening, we recommend that your child avoid contact sports or strenuous exercise for at least six weeks after the operation.
What happens afterwards?
Your child will be moved back to the ward when he or she woken up from the anaesthetic. It is possible he or she may still feel a bit sleepy. If your child had bone taken from his or her shinbone, there will be a bandage over the bone graft site, which can be removed in a few days time. Underneath the bandage is a small dressing, which should stay on until your child’s review appointment ten days after the operation.
Most children go home after staying overnight on the ward. Your child will need to stay on a soft diet for a couple of weeks to make sure that the graft heals well. He or she should avoid food with sharp bits, like crisps and peanuts, for a while.
As there is a chance of infection, your child will need a course of antibiotics. These will start in hospital but you should make sure you continue the complete course at home.
Your child’s mouth may be a bit sore after the operation. He or she will have been given pain-relieving medications during the operation, but these will begin to wear off. Your child will need to have regular pain relief for at least three days, so make sure you have some ready at home. As well as the medicines, distracting your child by playing games, watching TV or reading together can also help to keep your child’s mind off the pain.
By the time your child goes home, his or her leg or hip should be much more comfortable. The operation site will be covered with a dressing, which should stay in place until your child’s review appointment ten days after the operation.
The stitches inside your child’s mouth dissolve and usually fall out by themselves a few weeks after the operation.
It is very important that your child’s mouth is very clean after the operation. He or she should use a toothbrush and mouthwash after every meal. Your child can do no harm using a toothbrush! If your child’s mouth and teeth are not very clean, the bone graft can fail and may need to be repeated. For a short while after the operation, discomfort and stitches can make it harder to clean the mouth properly with just a toothbrush. We will give you some mouthwash to use at home twice a day. After meals a hot salt-water mouthwash can also be used, which will help with healing.
When you get home
You should call the ward if:
- Your child is in pain and pain relief does not seem to help.
- Your child shows any signs of infection – either the leg, hip or mouth is red, sore or oozing.
- Your child has a high temperature and paracetamol does not bring it down.
- Your child is not eating or drinking.
Your child will need to come back to the Maxillofacial Department ten days after the operation and then four weeks after that. Your child will need X-rays three months after the operation. These show whether the graft has been a success as well as helping to decide when to start orthodontic treatment. Usually no treatment is needed for some time after grafting, as the teeth are left to grow for a while without interfering.
Last reviewed by Great Ormond Street Hospital (GOSH): December 2014
Ref: 2014F0727 © GOSH Trust December 2014
Compiled by the Maxillofacial department and Peter Pan Ward at GOSH and the North Thames Cleft Lip and Palate Centre in collaboration with the Child and Family Information Group
This information does not constitute health or medical advice and will not necessarily reflect treatment at other hospitals. If you have any questions, please ask your doctor. No liability can be taken as a result of using this information.