الفهرس 
Introduction.Only 14 pages are availabe for public view
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Abstract
The closure of alveolar clefts remains a matter of debate among plastic surgeons. Centers dealing with this congenital anomaly apply different techniques at different stages of life. The literature on bridging the alveolar gap has been reviewed. Cleft lip is among the most common of congenital deformities. The prevalence of cleft lip with or without cleft palate and isolated cleft palate combined is about one per 650 live births .
Due to their detrimental effects on physical and psychological well being, a comprehensive approach is required for the management of these children. A wide range of clefts treatment protocols exists but the ideal surgical technique and timing protocol is a subject of ongoing debate. Systematic differences in craniofacial morphology, nasolabial appearance and dental arch relationships as well as in speech outcomes may occur between different cleft centers. Thus, both attempts to provide standards of care for these patients and analysis of clinical data in relation to these standards are very important
Secondary alveolar bone grafting is a well-established technique in the management of patients with cleft lip and palate; any patient with a cleft should be considered for grafting. Many sources of bone, both autogenous and alloplastic have been studied .
Historically, bone grafts have been used to treat patients with alveolar clefts since the beginning of the 20th century. Von Eiselsberg used the little finger as a pedicle graft in 1901, and Drachter used the tibia and periosteum in 1914. Since then the usual sites for harvesting autogenous bone have included iliac crest, cranium, chin, and rib; the greatest disadvantage being morbidity at the donor site. Today the procedure should aim at optimal physiological and psychological function with minimal impairment of growth and development in the maxillofacial complex.
autogenous bone from the iliac crest is the gold standard by which other types of alveolar grafts should be compared It is easy to access and can supply large quantities of cancellous bone with pluripotent or osteogenic precursor cells that support osteogenesis in the early period after grafting. Because of its higher content of osteogenic cells .
During the last two decades the use of the cranial bone grafts for maxillofacial procedures has been accepted. Its successful use at various craniomaxillofacial sites has led to its use to treat alveolar clefts. Both cortical and cancellous bone can be harvested from the calvarium in young patients,.
The mandibular symphysis is an attractive donor site with low morbidity and a satisfactory success rate for filling clefts. Its advantages include restriction to one intraoral site of operation, a shorter stay in hospital, minimal pain or discomfort, and an invisible scar in the lower labial sulcus. However, the restriction to one intraoral operating site.
The advantages of harvesting tibial cancellous bone are short operating time, minimal scarring, early mobility, and a short stay in hospital. However, the amount of bone harvested can be limited, and patients must be warned about the possibility that bone may be taken from both legs.
The use of autogenous bony substitutes for secondary alveolar bone grafts may reduce morbidity because it is not necessary to harvest autogenous bone, and would reduce the cost of rehabilitating patients with clefts. There is a growing interest in the use of bony substitutes to reconstruct craniomaxillofacial defect.
Boneless-bone grafting (gingivoperiosteoplasty) was popularized by Skoog in the 1960s and modified by others. Its use is one of the most widely debated areas in the treatment of patients with cleft lip and palate; its advocates are few, but are well-respected. They suggest that if healthy periosteum is closed over the alveolar defect, favorable osteogenic conditions would allow bone to bridge it However, the degree of ossification after gingivoperiosteoplasty varies between 50% and 100%, and a third step of bone grafting may be required .
Surgical treatment has been based on a number of assumptions, that the alveolar segments are hypoplastic and that the bony deficiency is surrounded by tissues of inferior quality which are inadequate for its restoration by normal growth. Thus the introduction of bone grafting has been a logical development. Since then, timing of such intervention remained controversial. Long-term studies of the effects of primary alveolar grafting on midfacial growth are conflicting, ranging from reports of no adverse effects on midfacial development, to reports of severe retrusion of the arch. Most centers dealing with cleft patients therefore prefer secondary methods of grafting. Potential disturbances in growth are thought to be minimal with this approach. However, Wiisenberg (1995) commented that the success of secondary bone grafting has been overemphasized. Complications of mucosal breakdown with loss of bone, resorption of bone graft, root resorption, failed tooth eruption and donor site morbidity have been documented by Berg land and associates (1986).
concluded that growth and development of the anterior maxilla is impaired to a variable degree in all forms of bone grafting techniques. Bone grafting at any age creates an unphysiological environment within the alveolar defect, increasing the incidence and degree of maxillary collapse and deformity. As an alternative to bone grafting, Skoog developed the periosteoplasty technique in which bone is formed within the alveolar cleft despite the fact that no bone graft is used.
Badran (1996) has used a personal technique utilizing the principle of boneless bone grafting.
He claimed that boneless bone- graft technique results in bone that has the characteristics of maxillary bone, can be modeled by orthodontia, and allows teeth to migrate into it. Although the concept is attractive, the procedure has not become widely accepted. has used a personal technique utilizing the principle of boneless bone grafting. His own personal clinical observation of the results was that they were good though not documented. With modern methods of investigation including impression casts, occlusal films, and 3DCT, the outcome of this technique can be better evaluated.