Alveolar Bone Graft (ABG) Surgery

If your child’s cleft affects the alveolus (the bone in the gum where the teeth sit), they will probably need surgery to fill the gap in their gum so that their adult teeth can erupt (come through) properly. A ‘bone graft’ involves borrowing a bit of bone from one part of the body to help repair another.

Preparation

• Assessment for this surgery will begin between 7 and 9 years of age, and the surgery itself will usually be completed by age 12.
• The orthodontist will often need to widen the area around the cleft to allow the surgeon to access it easier. This can involve a brace being fitted, most commonly a ‘quadhelix’. This takes place 6-9 months before the ABG surgery. The orthodontist may also want to arrange to take out some of your child’s top baby teeth next to the cleft. This will give them more room to work with inside the mouth.
• If your child is nervous about the surgery, you may be able to arrange a visit to the hospital so they can see where their bed will be and meet some of the people that will be looking after them. Reassure them that they will be asleep the whole time, and that numbing cream is usually available to help with any injections. They may also benefit from talking to another young person with a cleft who has already had their bone graft.

Bone graft tip sheet created by young people 

The Surgery

“Say which side of the hip you want the bone to be taken from – remember you will have a scar here for the rest of your life.”

• As with most surgeries, your child won’t be able to eat anything for a while beforehand. The hospital can give you specific guidance on this. This surgery will take place under general anaesthetic (where your child is fully asleep).
• During the procedure, bone marrow will be taken (usually from the hip, sometimes from the tibia (shin) bone) and grafted into the gap left by the cleft. If the bone is taken from the hip, a small cut around 5cm long is made low down on the tummy in an area that is usually covered by swimwear, a window is made in the outer surface of the bone and the inner marrow bone is scooped out. This is then closed and stitched up. The marrow will eventually grow back and the hip will be good as new.
• The mucosa (red tissue covering the bone of the gum) is then opened up and peeled away from the gap in the bone. The mucosa from each side is then stitched together to make a ‘pocket’, and the bone marrow is packed into this pocket so the entire gap is filled. The gum is then closed over the bone. The ‘floor’ of the nose may also be repaired at this time. This can help the bottom of the nose look straighter, but won’t change the shape of the face.
• Most children are admitted onto the ward the day before surgery and are able to go home the day after. Complications are rare and minor, and the scar on the donor site (hip or shin) will fade considerably with time.

After Surgery

• Afterwards, the ‘donor’ site where the bone was taken is often sore, and your child’s mouth will feel quite strange. They will have a ‘drip’ with painkillers to help ease the discomfort.
• Your surgeon will be able to advise on when your child will be able to eat and drink again. They’ll have to stick to ‘soft’ foods for a while after they go home until they’re healed.

“You will start to feel pain so don’t be afraid to ask for painkillers. It will be hard to talk and you might dribble so have a box of tissue’s nearby. You won’t be able to walk to the toilet straight away so you will need to use a commode – this is a wheelchair with a potty in it. I wanted to see how I looked, so asked the nurses for a mirror. Your face and area around your lip is likely to be swollen. This should get smaller within 2-3 days. I was a bit upset with my appearance, however you soon get back to normal.”

– Becky

“After the surgery you are advised to stick to a soft food diet, which isn’t as bad as it sounds! Ice cream is definitely the best medicine and it’s great for soothing your mouth if it’s sore after the surgery. Things like soups, mashed potato, yoghurts and smoothies are good as you don’t have to chew them and there are no sharp edges to worry about. Using plastic cutlery and cups is also a good idea as it doesn’t hurt as much if you do accidentally hit the sore area in your mouth.”

– Laura

“For me, I could eat most things as long as I could put them to the back of my mouth to eat them, (so I wasn’t putting any pressure on the bone graft site). I did have this special mouthwash to use after everything I ate, which was very annoying and didn’t exactly taste wonderful, but remember to use it…so nothing gets infected or anything, because that would be so painful!”

– Danielle

• It’s vital that the mouth is kept very clean for the first 10-14 days after surgery. This is because the bone placed in the gap will have ‘new’ bone growing around it, and at this time it’s very vulnerable to infection. Good, careful brushing and using a mouthwash recommended by your surgeon will help your child recover.
• Usually your child will need at least a week of school to make sure they don’t get an infection from anyone and can rest and recover. Any sporting activities should be avoided for at least two weeks, but check with your surgeon about this. It may take several weeks before the swelling of the face goes down and the inside of your child’s mouth starts to feel normal again.
• Your child will need to come back a few weeks after the operation so the consultant can make sure everything is healing properly. After 6 months, your child will have an x-ray to see how successful the treatment has been. It may take several months or even a year before the adult canine tooth erupts through the new bone graft. If teeth are crooked once they’ve come through, these can be straightened 3-6 months after the bone graft. Braces are usually not used until all a child’s permanent teeth have erupted into the mouth.
• Pyjama Fairies make free wrap pyjamas and surgical gowns specially designed for children who are having surgery, designed in such a way that your child can remain fully dressed when the medical team need to examine their abdomen, complete observations and administer medication.