With the exception of a few programs in the United States, most oral-maxillofacial surgery (OMS) residents do not train at a center where OMS is the primary surgical specialty on the cleft team that treats the patient from birth to adulthood. Therefore, for most residents, the earliest clinical exposure to patients with cleft lip/palate will be through the management of alveolar clefts, which are often performed by the OMS team. Thus, it is paramount that residents have a clear understanding of the implications of alveolar cleft surgery and the treatment of such patients. At our institutions, the University of Alabama at Birmingham (UAB) and Children's of Alabama (COA), our OMS department plays a key role in the cleft team. The primary repairs of the lip and palate and most soft tissue revisions are performed by the pediatric plastic and craniofacial surgeons at COA, with OMS performing the subsequent procedures, if indicated: alveolar cleft grafting, distraction osteogenesis, and orthognathic surgery. The foundation for the method and timing of the protocol is based on both scientific evidence and several decades of successful outcomes. We sought to share that experience with other residents in hopes that first, they are provided with a perspective that might be different from what they experience at their home program; and second, they might find some helpful strategies in the treatment of their own patients. Although the purpose and advantages of placing grafts in patients with alveolar clefts has been almost universally agreed on (and frequently asked by faculty in the operating room or on rounds), the actual process by which these patients are treated remains varied and, at times, controversial.1Boyne P.J. Sands N.E. Secondary bone grafting of residual alveolar and palatal clefts.J Oral Surg. 1972; 30: 87PubMed Google Scholar,2Precious D.S. A new reliable method for alveolar bone grafting at about 6 years of age.J Oral Maxillofac Surg. 2009; 67: 2045Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar The 2 main philosophical points of consideration are the timing of the graft and the source of the graft material. Although many sources have slightly varying definitions, the timing is determined by the chronologic or dental age and defined as primary, secondary, and tertiary (Table 1).3Lilja J. Alveolar bone grafting.Indian J Plast Surg. 2009; 42: S110Crossref PubMed Scopus (32) Google ScholarTable 1Graft Timing DefinitionsGraftingChronologic AgeDental AgePrimaryBirth to 2 yrBirth to 2 yrEarly secondary2-6 yrBefore mixed dentitionLate secondary6-15 yrMixed dentitionTertiary≥15 yrPermanent dentition Open table in a new tab Generally, primary and tertiary grafting are rarely performed. Secondary bone grafting has largely been considered the reference standard; however, the specific timing has varied across many centers. Traditionally, grafting will be performed after two thirds of the upper canine has formed and will often be performed after orthodontic treatment, including maxillary expansion.4Oberoi S. Gill P. Chigurupati R. et al.Three-dimensional assessment of the eruption path of the canine in individuals with bone-grafted alveolar clefts using cone beam computed tomography.Cleft Palate Craniofac J. 2010; 47: 507Crossref PubMed Scopus (57) Google Scholar At UAB, we aim to perform the grafting just before the eruption of the maxillary central incisors, before orthodontic treatment or expansion. This timing affords several advantages. First, the timing selects for younger patients who, overall, will heal faster, experience less pain and morbidity, have shorter hospitalizations, and will be less affected in their personal life.5Miller L.L. Kauffman D. John D S.t. et al.Retrospective review of 99 patients with secondary alveolar cleft repair.J Oral Maxillofac Surg. 2010; 68: 1283Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar,6Calvo A.M. Trindade-Suedam I.K. Filho O.G. et al.Increase in age is associated with worse outcomes in alveolar bone grafting in patients with bilateral complete cleft palate.J Craniofac Surg. 2014; 25: 380Crossref PubMed Scopus (16) Google Scholar Second, the positioning of, and periodontal support around, the maxillary incisors will often be improved if the teeth erupt through the graft, rather than performing the grafting around malposition or unsupported teeth. Third, this timing eliminates the need for preoperative orthodontic treatment, decreasing the overall treatment time and costs. Fourth, without preoperative expansion, the physical defect requiring closure will be smaller, lending itself to a lower repeat graft rate. Alveolar grafting has been performed from a variety of sources, including autografts from different locations, including allograft, xenograft, off-label use of recombinant human bone morphogenetic protein-2, or some combination of 2 or more sources. Anterior iliac crest bone (AICBG) has remained the reference standard material for alveolar grafting and has been the source used most frequently at UAB. Many of our patients undergo grafting at age 6 to 8 years. Thus, the AICBG procedure is straightforward and quick, can be performed through a small incision, causes minimal morbidity, and is well tolerated. Also, the cancellous bone allows for condensing, molding, and enlarging the arch. Other advantages offered by this technique include the decreased costs of the material, decreased likelihood of rejection, and an abundant source of vital cells. Harvesting an AICBG is a fundamental reconstructive procedure for the OMS and an enjoyable procedure for most residents. Craniofacial plastic surgeons ideally aim to introduce a patient with an alveolar cleft to the OMS department at approximately the age of 6 years or when the permanent mandibular central incisors are erupting. A traditional history and physical examination should be performed, including, at the least, a panoramic radiograph for imaging. The clinical and radiographic findings will indicate the timing of proceeding with surgery (ie, when the maxillary central incisors are nearing eruption). The first procedure performed is extraction of the remaining maxillary primary teeth adjacent to the cleft 4 to 6 weeks before the AICBG procedure. This allows for a uniform band of keratinized tissue to be used for retention of the graft material. Most of our AICBG procedures are performed at COA. Unless the patients and families have a specific preference, or if a specific contraindication is present, the left hip will be chosen for the AICBG. General endotracheal anesthesia is induced and an oral endotracheal tube placed and secured to the tongue with a silk suture and then taped down carefully to the midline of the patient. The patient is given preoperative cephalexin (or clindamycin) and dexamethasone. Both the oral sites and hip site are prepared and draped in standard fashion. The face and oral cavity are covered with towels, while the AICBG is performed sterilely through an iodophor surgical incise drape. Once sufficient cancellous bone has been harvested, the site is packed with microfibrillar collagen, and the cartilage cap and muscle are closed in layers using resorbable braided sutures. An elastomeric reservoir pain pump is secured to allow for continuous release of local anesthetic. The remaining fascia and skin are then closed in layers, including a final running subcuticular suture. Finally, the hip site is protected from contamination. Attention is then turned to the oral cavity. Scalloped incisions are performed, and mucoperiosteal flaps are elevated. Careful separation of the buccal mucosa, palatal mucosa, and nasal mucosa within the cleft is performed to ensure watertight closure of the nasal mucosa. The defect is then grafted using the cancellous bone and a small amount of demineralized bone matrix putty. Primary mucosal closure and interdental closure are performed. This is more readily performed without orthodontic appliances present, which will make the procedure more difficult to perform and more difficult for the patient to maintain the postoperative hygiene required. Finally, the patient is extubated and admitted to the surgical floor. Unless medical contraindications dictate a change, nearly all patients will start scheduled acetaminophen, ibuprofen, antibiotics, and steroids. A very small number of patients will require additional pain control, which will usually involve a single dose of narcotic medication (oral or intravenous). They are encouraged to ambulate in the room and drink clear liquids as tolerated. From a resident perspective, these patients are extremely straightforward to treat. Most patients will have limited comorbidities and have rarely had postoperative issues or complain. Nearly 100% of our patients, including 100% of the patients in our study, will be discharged the next day. The pain pump catheter was removed just before discharge, and the patients will rarely be prescribed narcotic pain medications at discharge. The vast majority of the patients will heal very quickly in a routine and predictable manner. By achieving watertight closure of the nasal floor and primary closure of the oral mucosa using the healed previous extraction sites, graft retention and soft tissue healing have rarely been an issue. Once we have ensured that the patient is progressing as expected, we begin postoperative orthodontic treatment, which can include expansion, at ∼3 to 6 months after grafting. In conclusion, the treatment of patients with an alveolar cleft is a fundamental part of our scope of practice. Understanding the implications regarding the timing of the graft and the source of the graft is paramount to optimizing the patient's overall experience. At our institution, we believe that using the AICBG to perform the graft just before the eruption of the maxillary central incisors allows for predictable results, minimal patient morbidity, and decreased treatment time and the number of procedures for the patient. As OMS residents with a strong foundation in dentistry, we understand the importance of improvements in facial growth, esthetics, speech, occlusion, dental eruption patterns, periodontal health, orthodontic principles, and oral hygiene. That knowledge provides an excellent opportunity for OMS to be involved with cleft care and provides the necessary insight to improve patient outcomes.