Reduced Need for Alveolar Bone Grafting by Presurgical Orthopedics and

Primary Gingivoperiosteoplasty
PEDRO E. SANTIAGO, D.M.D.
BARRY H. GRAYSON, D.D.S.
COURT B. CUTTING, M.D.
MARK P. GIANOUTSOS, M.D.
LAWRENCE E. BRECHT, D.D.S.
SOON MAN KWON, D.D.S.

Objective: The purpose of this study was to evaluate if narrowing and ap-
proximation of the alveolar cleft through presurgical alveolar molding followed
by gingivoperiosteoplasty (GPP) at the time of lip repair reduces the need for
a bone-grafting procedure.
Design: This was a retrospective blind study of patients with unilateral or
bilateral alveolar clefts who underwent presurgical infant alveolar molding and
GPP by a single surgeon. Alveolar bone formation was assessed prior to the
eruption of the maxillary lateral incisor or canine by clinical examination, pan-
oramic and periapical radiographs, and/or a dental CT scan. The criterion for
bone grafting was inadequate bone stock to permit the eruption and mainte-
nance of the permanent dentition.
Setting: This study was performed at the Institute of Reconstructive Plastic
Surgery by the members of the Cleft Palate Team.
Patients: All patients with unilateral (n 5 16) or bilateral (n 5 2) alveolar clefts
who underwent presurgical infant alveolar molding and GPP by a single sur-
geon from 1985 to 1988 were studied. The control population consisted of all
alveolar cleft patients (n 5 14) who did not undergo alveolar modeling or GPP
during the same time period.
Interventions: Presurgical alveolar modeling was performed with an intraoral
acrylic molding plate. This plate was modified on a weekly basis to align the
alveolar segments and close the alveolar gap. The surgical intervention con-
sisted of a modified Millard GPP.
Main Outcome Measures: The primary study outcome measure was the elim-
ination of the need for a secondary bone graft in patients who underwent pre-
surgical alveolar molding and GPP.
Results: Of the 20 sites in the 18 patients who underwent GPP, 12 sites did not
require an alveolar bone graft. Of the 8 sites requiring a bone graft, 4 presented
minimal bony defects. All 14 patients in the control group required bone grafts.
Conclusions: In this series of 20 alveolar cleft sites treated with presurgical
orthopedics and GPP, 60% did not need a secondary alveolar bone graft in the
mixed dentition.

KEY WORDS: alveolar bone grafting, presurgical orthopedics, primary gingivo-

periosteoplasty

Dr. Santiago is Associate Professor and Graduate Director, Department of Orthodontics, University of Puerto Rico School of Dentistry, Walter Lorenz
Surgical Orthodontic Fellow in Craniofacial Anomalies and Dentofacial Deformities. Dr. Grayson is Associate Professor of Clinical Surgery (Orthodontics);
Dr. Cutting is Associate Professor of Surgery, Director, Cleft Lip and Palate Team; Dr. Brecht is Assistant Professor of Clinical Surgery (maxillofacial
prosthetics), Director of Dental Service; and Dr. Kwon is Visiting Surgical Orthodontic Research Fellow, Institute of Reconstructive Plastic Surgery, New
York University Medical Center, New York, New York. Dr. Gianoutsos is a plastic craniofacial surgeon, Sidney Children’s Hospital, Sidney, Australia. Dr.
Grayson is also a professor, Department of Orthodontics, New York University College of Dentistry, New York, New York. Dr. Brecht is also Clinical
Associate Professor of Prosthodontics and Director of Maxillofacial Prosthetics, Division of Restorative and Prosthodontic Sciences, New York University
College of Dentistry, New York, New York.
Presented at the 53rd Annual Meeting of the American Cleft Palate–Craniofacial Association, San Diego, California, April 1996.
This study was supported by funds provided by The Walter Lorenz Surgical-Orthodontics Fellowship.
Submitted June 1996; Accepted June 1997.
Reprint requests: Dr. Court B. Cutting, New York University Medical Center, Institute of Reconstructive Plastic Surgery, 550 First Avenue, New York,
NY 10016.

77
78 Cleft Palate–Craniofacial Journal, January 1998, Vol. 35 No. 1
The purpose of this retrospective study was to evaluate the
extent to which presurgical infant orthopedics (PSIO), when com-
bined with gingivoperiosteoplasty (GPP), eliminates the need for
alveolar bone grafting in the mixed dentition period. Gingivoper-
iosteoplasty is the primary repair of the gingivoperiosteum at the
site of an alveolar cleft, with the intention of forming an osseous
union. This approach has recently been advocated by Millard and
Latham (1990). This new method is quite different from the pure-
ly surgical approach of Skoog (1965), in which preoperative or-
thopedics was not used, and wide subperiosteal undermining was
employed. With presurgical orthopedics, gingivoperiosteal repair
can be performed with minimal undermining and with a narrow
bone gap that must be bridged. Previously, all children with com-
plete alveolar clefts were likely to require an alveolar bone graft
during the period of mixed dentition. Narrowing of the alveolar
cleft and approximating the lateral segments through presurgical
infant orthopedics followed by GPP at the time of lip repair may
eliminate the need for this bone graft. This article examines the
incidence of bone grafting in a group of patients treated with this
method after 8 years of follow-up.
METHODS
Thirty-two infants (30 with complete unilateral and 2 with bi-
lateral clefts of the lip and maxillary alveolus) were included in
the study. The mean age at the time of lip surgery with GPP was
3.5 months (SD 5 20.6 days). Eighteen patients (20 cleft sites)
underwent a course of PSIO to bring their alveolar segments into
alignment and to reduce the width of the alveolar cleft prior to
lip repair. Dental casts of the pretreatment defect were examined,
and the original sizes of the clefts between the medial and lateral
segments were measured by multiple observers using calipers.
The mean alveolar gap at the start of PSIO was 6.14 6 4.11 mm
(SD). A primary lip and nasal repair was performed along with
a GPP by a single plastic surgeon (C.B.C.).
The GPP method employed was that described by Millard
and Latham (1990), with several modifications. Only one Z-
plasty at the alveolar ridge is employed if a gap is present. As
the labial surface of the gingiva is more difficult to bridge than
the palatal surface because of the increased circumference on
the outer aspect of the arch, the incision on the edge of the
alveolus is biased in on the palatal side. An everted closure
using a vertical mattress technique is used to prevent the flaps
from becoming interposed between the medial bone and the
lateral bone. In closing the nasal floor, the L flap is pedicled
on the lateral nasal wall (Cutting and Grayson, 1993). The
septal flap is closed to the lateral nasal-floor flap in continuity
with the inferior edge of the L flap. Thus, using the L flap to
fill any defect along the piriform aperture does not result in a
nasolabial fistula. The gingival flaps are very small and de-
veloped at the cleft margins of the alveolus only. Subperiosteal
dissection does not extend over the face of the maxilla or over
the palatal surface. We prefer to have the alveolar segments
tightly together before surgery. Unlike Millard, we perform
the GPP together with formal lip and nose repair in one stage.
Fourteen patients who underwent lip and nasal repair alone
without GPP served as controls. This group did not undergo
a course of PSIO for one of two reasons: (1) they presented
to the Cleft Palate Team at an age that was too late for effective
PSIO by our protocol, or (2) the parents were not compliant
with the treatment protocol, and PSIO was terminated early
without achieving presurgical alignment of the alveolar seg-
ments. The mean alveolar gap in this subgroup was 7.36 6
5.62 mm. All children in both groups were evaluated in the
mixed-dentition period. Mean postoperative follow-up was 8.1
6 1.21 years. Bone formation was assessed by clinical ex-
amination, periapical and panorex dental radiographs, and/or
Dentascan CT scan of the maxilla. The criterion for bone graft-
ing was inadequate bone width, height, and thickness to permit
the eruption and maintenance of the permanent dentition (Fig.
1A and 1B). Specific parameters included alveolar height on
the cleft side (unilaterals), comparison of alveolar bone height
and width adjacent to the lateral incisor, and canine root length.
If alveolar height and width appeared to be adequate, but a
lucent area was present within the cleft, a dental CT scan was
performed to further define the defect. Our team was conser-
vative and performed bone grafts if any doubt existed regard-
ing the adequacy of the alveolar bone for the periodontal sup-
port of the adult dentition (Fig. 2A through 2C).
RESULTS
Of the 20 sites that underwent GPP, 12 did not require an
alveolar bone graft when evaluated in the mixed-dentition stage.
In the group of 8 who subsequently required alveolar bone grafts,
4 presented with minimal residual bony defects. All 14 patients
in the control group required bone grafts in the period of mixed
dentition. Chi-square analysis of a difference in bone graft inci-
dence was statistically significant (p , .01). The ages at the time
of evaluation were 8.1 6 1.21 years for the GPP group and 7.56
6 0.88 years for the controls. Student’s t test did not reveal a
significant difference between the mean alveolar cleft sizes at
initial presentation (prior to surgery) in the patients who did not
require an alveolar bone graft and those who did (t 5 .1512; NS).
The mean alveolar gap at the start of treatment for the presurgical
infant orthopedic group was 6.14 6 4.11 mm and for the control
group, it was 7.36 6 5.62 mm.
DISCUSSION
There has been considerable debate regarding the capacity
of periosteum to form bone. In 1867, Ollier clearly demon-
strated the osteogenic potential of periosteum. In 1928, Bull
gave an extensive review of the literature on the subject. Sirola
(1960) demonstrated the indisputable role of periosteum in re-
generation of membranous bone in experimental animals.
There have since been many studies showing variable amounts
of bone regeneration from periosteum, with the age of the
animal appearing to be a significant factor and with younger
animals exhibiting better bone formation (Ritsila et al., 1972).
The osteogenic potential of periosteum has long been rec-
ognized, particularly for its application in the surgical treat-
ment of cleft defects of the alveolus and palate. Skoog (1965)
was particularly interested in advancing this area. His enthu-
siasm was sparked by his clinical observation of two patients
 Santiago et al., BONE GRAFTING AND GINGIVOPERIOSTEOPLASTY
FIGURE 1 A: Detail from panoramic radiograph showing adequate bone
formation in the site of a gingivoperiosteoplasty between the left central
and lateral incisors (arrow). This patient, with bilateral clefts, needed a
bone graft on the contralateral side. B: Intraoperative view of the same
patient showing the side that did not need a secondary alveolar bone graft.
Note the complete bony union and full alveolar contour. A 5 gingival tissue
above left maxillary incisors; B 5 buccal alveolar bone formed at the site
of a gingivoperiosteoplasty; C 5 minimal residual alveolar cleft descending
from the floor of the piriform aperture; D 5 deciduous maxillary incisors.
in whom periosteum had united across a cleft maxilla and de-
posited solid bone (Skoog, 1965). Unlike present practice,
Skoog’s surgical technique included extensive undermining of
the periosteal tissues. Unfortunately, Skoog did not have the
advantage of approximating the lateral alveolar segments and
reducing the size of the cleft gap through the use of presurgical
infant orthopedics. Instead, he attempted to close wide alveolar
79
cleft gaps using broad undermining of the periosteum on the
face of the maxilla. In the technique described in this article,
periosteal undermining is extremely limited because of the pre-
surgical reduction in cleft gap width. Pritchard (1946) looked
at the size of ‘‘fracture gaps’’ and bone healing. He observed
that the rate of bone healing was inversely proportional to the
size of the gap. For this reason, PSIO preceding GPP may be
expected to produce more satisfactory bone formation. Others
have successfully employed the technique of periosteoplasty.
For example, O’Brien (1970) confirmed the formation of bone
within 6 months following surgery. He also reported an ap-
parent lack of interference with subsequent maxillary growth
following periosteoplasty. Rintala et al. (1974) reported that
54% of their patients who had undergone periosteoplasty de-
veloped a bone bridge and that 22% demonstrated a diffuse
bridge after the procedure, while bone failed to form in 24%.
Ohmori and Hata (1977) reported that 65% of their patients
showed some bone formation following periosteoplasty.
Presurgical infant orthopedics is a standard feature of our
protocol for the management of both unilateral and bilateral
clefts of the alveolus and palate, and it allows the close ap-
proximation and proper alignment of the alveolar segments
prior to surgical repair. When PSIO precedes the GPP, a more
limited and atraumatic dissection can be achieved, requiring
less undermining of periosteal flaps.
The finding of 60% elimination of bone grafting reported
here is probably lower than the percentage that will be ob-
served later in the series. The patients who form the basis of
this report were the first to be treated by our group. Both our
success in narrowing the alveolar cleft with PSIO and the qual-
ity of GPP have improved significantly as our experience with
these techniques has grown. For this reason, we expect the
next generation of children treated by this method to exhibit
higher success rates. Placing osteoinductive proteins into the
GPP site may also increase the success rate in the future.
The GPP technique that we employed differs somewhat from
that described by Millard and Latham (1990). While they find it
easier to work with a small residual cleft gap, we prefer to have
the alveolar segments tightly together before surgery. Although
GPP is more difficult technically, we expect that the narrower the
‘‘fracture gap’’ is, the better the bone formation will be (Pritchard,
1946). The labial surface of the gingiva is more difficult to bridge
than is the palatal surface because of the increased circumference
on the outer aspect of the arch. Elevating the palatal flaps results
in easy apposition with little chance of the flaps falling between
the raw bone surfaces. In contrast, on the labial side, extra gin-
gival flap length is required to assure complete bridging of the
cleft. Millard performs the GPP along with a lip adhesion as a
first procedure, followed some months later by formal lip repair.
We perform the GPP together with the formal lip and nose repair
in one stage. Although the two-stage approach offers some the-
oretic benefits to facial growth, we have not observed it in the
two groups.
Wood et al. (1993, 1997) examined the effect of GPP on
maxillary growth and were unable to show a significant dif-
ference in growth in cleft patients whether or not they under-
80 Cleft Palate–Craniofacial Journal, January 1998, Vol. 35 No. 1

FIGURE 2 A: Periapical radiograph of a patient showing an alveolar bone defect of questionable dimensions. In this view, the defect appears to be limited
to the apical region of the teeth. If this were the case, the patient might not need a bone graft to achieve the objectives of canine eruption and orthodontic
alignment of the teeth. B: This coronal cross section from a CT scan (Dentascan) of the alveolar process shows a wide bone defect (arrow) on the midportion
and palatal wall of the alveolar crest, suggesting the need for an alveolar bone graft. The extent and clinical implications of this defect could not be
appreciated with the conventional periapical radiographic view in A. C: This panoramic view from the CT scan (Dentascan) shows another perspective of
the area of interest (arrow), corroborating the need for bone graft reconstruction of the alveolar defect.

went GPP. Interestingly, the authors also demonstrated that the
scatter of values for maxillary position was much greater for
those cleft patients not treated with GPP, suggesting a more
uniform approximation of the alveolar segments with GPP, re-
sulting in a more uniform position of the hard palate (anterior
nasal spine to posterior nasal spine). Presurgical infant ortho-
pedics produces a more normal alignment of the cleft segments
that is subsequently maintained by GPP. It should be noted that
this growth study was performed in the mixed-dentition stage
and that follow-up studies of this population are planned. Even
if midface growth is affected, the procedure may still be ben-
eficial overall. If GPP increased the number of late LeFort I
advancements, this would have to be contrasted with the num-
ber of alveolar bone graft procedures eliminated by GPP.
Significant benefits of GPP are seen even when incomplete
formation of a bone bridge occurs. Four of the eight patients with
inadequate bone had graft recipient sites showing residual bridges
and thin plates of bone following the original GPP. In these four
cases, the presence of the residual bone and its periosteal tissues
enhanced the environment for the placement and eventual incor-
poration of the bone graft. In all eight patients who required bone
grafts, no oral or nasal fistulas were present at the time of the
graft procedure. The isolation of the oral and nasal environment
from the site of the bone graft by complete sheets of oral and
nasal mucosa further enhanced the prognosis for the bone graft.
It was also noted that the site of failure of bone formation fol-
lowing GPP was the inverse of that seen following secondary
alveolar bone grafting. Eruption and downward migration of the
primary teeth in a partially successful GPP tends to carry the
bone bridge down to the alveolar ridge, leaving a residual bone
gap up near the piriform aperture. This is the area where second-
ary alveolar bone grafting is most successful. Again, we would
have expected a higher success rate with alveolar bone grafting
had a primary GPP been performed earlier.
Patients with complete bilateral clefts have a two-thirds
probability of failure of their GPPs, suggesting that only one
third of the patients with bilateral clefts will not require bone
grafting. Even in this group, however, maintenance of pre-
maxillary position, the absence of anterior fistulas, and a fa-
vorable periodontal situation with premaxillary stability on at
least one side may still commend the GPP procedure.
CONCLUSION
In 60% of the alveolar cleft sites studied, bone grafting in
the mixed dentition was eliminated by the use of a combined
approach of presurgical infant orthopedics and GPP. Eighty
percent of the cleft sites undergoing GPP showed some bone
formation, while 20% showed minimal or no bone develop-
ment. In contrast, the entire control group required alveolar
bone grafting. No correlation could be made between the size
of the alveolar cleft at the time of initial presentation and the
need for alveolar bone grafting.
REFERENCES
Bull CR. Experimentelle Studien uber Knochentransplantation und Knochen-
regeneration. Skrifter utg av det Norske Videnskaps-Akad. Oslo: Mat na-
turvet klasse 1, 1928, No. 9.
Cutting C, Grayson B. The prolabial unwinding flap method for one-stage repair
of bilateral cleft lip, nose and alveolus. Plast Reconstr Surg 1993;91:37.
Millard DR, Latham RA. Improved primary surgical and dental treatment of
clefts. Plast Reconstr Surg 1990;86:856.
O’Brien B. The maxillary periosteal flap in primary palate surgery. Aust N Z
J Surg 1970;40:65.
Ohmori S, Hata Y. Presentation at the International Congress of Plastic Surgery,
Toronto, Canada, 1977.
Ollier L. Traite Experimental et Clinique de la Regeneration des Os et de la
Production Artificielle du Tissue Osseux. Paris: V Masson et fils, 1867.
Pritchard J. Repair of fractures of the parietal bones in rats. J Anat 1946;80:
55.
Rintala A, Soivio A, Ranta R, et al. On the bone-forming capacity of periosteal flap
in surgery for cleft lip and palate. Scand J Plast Reconstr Surg 1974;8:58.
Ritsila V, Alhopuro S, Rintala A. Bone formation with free periosteum. Scand
J Plast Reconstr Surg 1972;6:51.
Sirola K. Regeneration of defects in the calvaria. Ann Med Exp Blot Fenn 1960;
38(suppl 2).
Skoog T. The use of periosteal flaps in the repair of clefts of the primary palate.
Cleft Palate J 1965;2:332.
Wood R, Grayson BH, Cutting C. Gingivoperiosteoplasty and growth of the
midface. Surg Forum 1993;16:229.
Wood RJ, Grayson BH, Cutting C. Gingivoperiosteoplasty and midfacial
growth. Cleft Palate Craniofac J 1997;34:17–20.