In response to this question, I can only find experience based recommendations in the literature that differed from as early as 3 weeks to as late as 12 weeks. There is a single animal experiment from Japan (Uji, 1996) in cats that compare one week and 8 weeks, but the experimental model does not really mimic that of a cleft. Recently, a couple of studies addressed the issue of moving teeth into the post distraction bone regenerate which may be considered quite similar. Does anybody know any research-based recommendations done on cleft material?
We usually allow three months of healing. If on clinica exam there is no fistula and radiographic shows consolidation of graft, the orthodontist can proceed with tooth movement.
Waiting too long will lose the graft. In the first 6 months there is maximum bone loss and it continues for one year while most of the bone is lost in a cleft patient. What we achieve with the bone graft is successful closure of the fistula and healthy tissue. Also the quality of graft can be a factor. Particular grafts take up soon but show resorption or loss early as they remodel fast. Particulate bone grafts show neovascularization as early as 2 weeks while block grafts take atleast a month to vascularize.
As Dr Napoli pointed out, a period of 3 months can be beneficial especially in patients with large preoperative clefts sizes. Once the graft has vascularized, it can support a tooth and infact stress and strain from the orthodontic movement acts as a stimulant for bone consolidation and new bone formation. So, early orthodontic tooth movement is beneficial.
At best what I am recommending can be considered as a low quality of evidence as it is just an 'expert opinion'.
Will try to review literature and write more later when I have more time.
Regards,
Dr. Akilesh R
Consultant Oral and Maxillofacial Surgeon
India
Waiting for three months would be a sufficient time post bone augmentations...
As a Periodontist I beg to differ, as one should wait for at least 6-9 months. Because after bone grafting sometimes the bone formation continues till 6-9 months and then it undergoes remodelling. Though studies have to be conducted to quantify the linear model of role stresses of Orthodontic movement having a positive or negative effect. Because the response to ortho forces on sound bone and grafted sites can not be equated.I woul always be better if you start moving the tooth to the grafted site once it becomes clear that the new bone formed has entered its remodelling stage.
Usually 6 months after grafting is the wait before the movement of teeth. Consulting with a periodontist is necessary to make sure that the graft has healed properly before tooth movement can be undertaken.
It reminds me the other question: how long should we recommend soft diet following secondary bone grafting (SABG)? It depends on many factors, hence there is no one simple answer. Anyway, I am glad that in our center we perform early SABG (around 2-3 year of age) as a routine. Naturally in that situation those two questions are irrelevant in the majority of our cleft cases. In the 9-10-year-olds I recommend to wait at least 3 months with orthodontics and normal diet, especially when bone block graft was used and perhaps not longer when bone cement was used.
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