Cleft Palate

Secondary Bone Graft

Childhood  Ages 6 to 12 

Preparation Before the Surgery 

• Before assigning a surgery date, we need to discuss with your orthodontist as to the appropriate timing of surgery. Many patients will benefit from initial braces and palatal expansion prior to the bone graft.  Some will benefit having the bone graft first followed by braces.  Additionally, any baby teeth adjacent to the cleft need to be removed 4-6 weeks before surgery.  This will allow the tissues to heal so that there are no holes left where the baby teeth were removed.  

• Our office coordinates the scheduling of surgery typically Wednesday. Please make sure we have a good contact number for us to reach you. 

• This procedure is covered by insurance providers and we have never had difficulty in obtaining approval. 

• Please let your orthodontist know of the date of surgery as soon as possible. There may be orthodontic adjustments that need to be done before the surgery. 

• Even though we assign a surgery date, there is a small possibility of a last minute change because of the urgency of other cases (cancer, transplant, trauma) in the operating room. We appreciate your understanding and apologize for the inconvenience. 

• Oral and Nasal Care 

  • Oral and nasal care  is IMPORTANT for normal healing and to minimize complications (infection, breakdown) 

  • Parents are expected to monitor their child's oral care. 

  • Brush teeth and gums  3 times a day 

  • Rinse mouth with anti-gingivitis type mouth wash  3 times-a-day after brushing 

  • Rinse nose with saline (salt water) at least 2 times-a-day 

  • Dental cleaning within a 4-6 weeks before surgery, if possible 

• Ideally, it is helpful to have the following at home before the surgery: 

  • Child Ibuprofen (Motrin/Advil) 

  • Narcotic prescription filled  

  • Antibiotic prescription filled 

• Please make an appointment with your pediatrician 2-4 weeks before the surgery. Please have their office complete the history/physical form needed by our anesthesiologists. Please fax this to our office and bring a copy with you at the time of surgery.  If you do not have the form, please contact our office. 

• The Hospital will contact you and give you the time of surgery and when to stop feeding your child. 

• Please arrive 60 minutes before the scheduled time of surgery. It is better to be early than late.  The surgery may be rescheduled depending on the other surgical cases in the OR. 

• If your child is developing a cold or has had a cold within 2 weeks of surgery date, the surgery will need to be re-scheduled. We cannot do the surgery if the child is ill or is becoming ill. The tissues will not heal. Please contact our staff as soon as possible. 

The Day of  Surgery 

• The surgery is done under general anesthesia 

• Bone graft: Borrow a small segment of hip bone (1x1in / 2.5x2.5cm) 

• The procedure takes approximately 2-3 hours  

• I will call you and see you as soon as the surgery is done 

• You will see your child in the recovery room 

• It will take an additional 2-3 hours before you can go home 

• This procedure is considered out-patient surgery (only in rare circumstances does the child need to stay overnight). 

Recovery After the Surgery 

Controlling Pain and Discomfort
Ibuprofen (Motrin / Advil) for the first 2-3 days continuously, use narcotic (such as Lortab) sparingly. Consider alternating the pain medication if needed, DO NOT JUST TAKE NARCOTICS. Follow the directions on the label based on the child's weight/age (do not take more than the recommended dose). Pain control is mainly needed for the first 3-5 days after surgery, thereafter as needed 

Facial Swelling/Bruising
Expect facial swelling and occasional bruising. The swelling is worst the first 3 days after surgery. By the end of the week, it is significantly less. Use washcloths soaked in ice water or frozen 'peas' or any commercially available product especially the early days after surgery.  Please also have your child sleep with an extra pillow or two.  The swelling is worse in the morning with lying down.  Being up and active will help the swelling to come down faster. 

Antibiotics
Follow the directions on the antibiotics.  If you miss a dose do not double it. If your child develops diarrhea, please discontinue the antibiotics.  

What to eat
First few days stick to more liquids so that it is easier to keep the mouth clean. Begin slowly after the surgery to minimize nausea and to easily clean the mouth after eating. Encourage liquids after surgery as much as possible to avoid dehydration. This will help the tissues to heal. (Children can easily become dehydrated). After a day or so, start with a soft diet (Jello, puddings, soups to pasta), and continue the soft diet for the first 2 weeks after surgery thereafter there is no restriction. 

General Care
Wash and bathe normally the day after surgery. There are no restrictions in daily activities or positioning in sleeping, gradually increase every day. Most of the children are recovered by 1 week after surgery. Contact sports should be avoided for 6 weeks after surgery. 

Operative Site Care of the Bone Graft
The tape over the site where the hip graft was taken will come off on its own within 10-14 days. 

Nasal Care
Continue the salt water (saline) nasal spray after surgery for at least 6 months. Use a humidifier or vaporizer. This will help with the nasal passageways. Occasional nasal bleeding and crusting may continue from weeks to months after surgery. 

Oral Care
First 3 days, rinse mouth frequently with a mixture of hydrogen peroxide and water (equal parts 1 to 1).  Rinse 4-6 times a day to remove blood and any food left behind. Once there is no blood in the mouth then use salt water mouth rinse or an anti-gingivitis mouth rinse. Rince 4-6 times a day. Start brushing the teeth at 1 week after surgery, 3 times a day. At 2 weeks after surgery, start gently brushing the gums or use your finger and toothpaste to clean the gums above the teeth each time you brush. Use a brush with a small head and soft bristles. This will help remove the remaining sutures and help the gum tissue to heal. Good oral care is IMPORTANT for healing. 

Follow Up Appointment with the Surgeon 

Appointment 2-4 weeks after surgery
Appointment   6 months after surgery
Appointment 12 months after surgery 

The Success and Failure of Bone Grafts 

• A few weeks to months after surgery sometimes the bone graft can become exposed.  This is because of the active dental development that occurs and 'pushes' the graft before it becomes incorporated. 

• Sometimes a small chip of the bone graft may fall out. This is OK. There is excess bone placed.  Continue to care for the site as above. 

• Clean the area with a Q-tip soaked in warm salt water 2 to 3 times a day. This will help the mucosa to heal over it.  

• Make an appointment to come see us when this happens. It is not urgent. 

• The grafts primary purpose at this age is to support the adjacent teeth and to allow permanent teeth to come through the bone graft. 

• The success rate is 95%+ for a one-sided cleft and 85% for double-sided cleft. 

• But whether there is enough bone to support a dental implant that may be needed in adulthood cannot be predicted.  That depends on the teeth development. 

• Assess the outcome 8 to 12 months after the surgery with x-rays.  

• Please continue to make regular appointments with me at 6-month intervals

Where is the bone taken from? 

• A small section of hip bone is used.  An incision is made and bone is removed from the inner surface of the hip.  This is about 1x1 in or 2.5x2.5cm bone.  Additionally, the soft inner bone (marrow) is also used. 

• Artificial bone doesn’t work because it doesn’t grow and develop with the childlike real bone.  Bone taken from other people usually is rejected or disappears. 

• Other bone generating substances (BMP) have been used, but these have not provided a consistent result or sufficient volume. 

How is the bone graft placed? 

• All the surgery is done inside the mouth on the gum tissue and behind the upper lip.  The lip repair is not taken apart.  

• Cuts are made along the edges of the gum and in the pink lining tissue, the gingiva, and mucosa.  

• The bone edges are exposed and a small pocket is made on either side of the cleft.  

• The bone graft is placed to reconstruct the floor of the nose and the roof of the mouth. 

• Bone is filled between the gap 

• The lining tissue of the palate and the gum is repaired. 

• It is important to remove baby or permanent teeth that will not be used at least 6 weeks before the surgery. As these will leave 'holes' in the gum lining and will need 3-4 weeks of healing time. 

• The quality of this lining tissue is important as it covers the bone graft and provides the blood supply needed for the bone to live. 

• In double clefts, the gingival mucosal tissue is of poor quality and has a poor blood supply. Sometimes this needs to be staged as to separate operations or a repeat operation. 

• This a very simple explanation of one way of how it can be done. How it is exactly done for each child will depend on the severity of the deformity.  

Risks, Complications, and Outcome? 

• Risks of general anesthesia (discussed by an anesthesiologist)  

• Infection and bleeding 

• Temporary or permanent loss of a sensory nerve in the region of the thigh from the bone graft. 

• Outcome: Most bone grafts are successful. They accomplish the major goal of the surgery which is to the dental development and nasal support. But there is a percentage of children who may need additional bone later in childhood to replace a missing tooth that will need an implant. This is because the thickness (volume) may not be enough to support the implant. The need for an additional bone graft can only be determined 8-12 months after surgery with an x-ray. It is rare for a bone graft to completely fail, if this occurs it is usually due to poor blood supply, infection or some unusual circumstance.