The Alveolar Bone Graft (ABG) operation

If your child’s cleft affects their gums, they will meet with their orthodontist and cleft surgeon at around seven or eight years old.

An x-ray will be taken to see if there is a gap in your child’s alveolus (bone in the gum), and to check how their adult teeth are growing underneath the gums. The x-ray will also show if your child has any extra or missing teeth around the cleft, as this is fairly common.

These x-rays will give the Cleft Team the information they need to decide whether or not your child needs an ABG and when the best time for the surgery will be.

The cleft team may need to do these checks several times before they can say for sure what’s needed, as all children grow and develop at different rates.

Some children need orthodontic treatment (usually braces) to prepare the teeth around the alveolar cleft before the surgery. The braces will help to straighten the teeth and may gently open the gap in their gum to make sure the surgeon has enough space to work.

The braces might be removable at night, or fixed (‘glued’) to their teeth. They might only be needed for the top teeth.

They’re usually needed for around a year before the operation, though some children will need them for longer.

The orthodontist will discuss this as part of the assessments when preparing for an ABG operation. Talk to your child before any appointments to make sure you discuss any questions or worries they may have about getting braces.

When the orthodontist believes the teeth are ready for the ABG, either the braces will stay on, or a smaller brace will be fitted. This will hold the teeth in their new position until the date of the operation.

For dental and orthodontic treatment to work, teeth need to be kept as clean and healthy as possible, so tooth brushing is a top priority. It can be tricky to clean the teeth properly when braces are on, so your child’s orthodontist will show them how to keep their teeth clean.

It is also important they avoid lots of sugary food and drink, as these can damage their teeth, and to not eat sticky foods as these can break their braces.

This video from the British Orthodontics Society can help to explain how to look after braces properly:

CLAPA also has resources aimed at young people to help them to look after their braces.

Sometimes there are still some baby teeth in the area where the bone graft is going to be placed. Having these baby teeth removed gives the orthodontist and surgeon more room to work inside the mouth.

Sometimes these baby teeth can be tricky to remove in advance, so they’ll be removed as part of the ABG operation.

Your child will have an appointment in the clinic with the Cleft Team where they will explain the operation.

This is a good place to share any questions or concerns. It can be helpful to talk to your child about this before the appointment and make a list of questions together. Read more about supporting your child at this time.

You will be asked to sign a consent form if you are all happy to go ahead with the operation.

Before the operation, your child will have a ‘pre-assessment’ (a medical check-up at the hospital or over the phone) to check they are fit and healthy.

You will be told the date of the operation in advance so there’ll be time for your child to prepare for the surgery (e.g. by packing a bag), and for you to notify their school and take any necessary time off work.

It is normal to feel worried about an operation – but there is lots of support available!

Your Cleft Team will be happy to answer any questions you may have or talk through any worries; the Clinical Psychologist is also available for you and your child.

Encourage your child to talk about any concerns they have any note down any questions you don’t know the answer to; you can bring these to the Cleft Team together.

• A pair of pyjamas or nightdress, which are loose fitting and easy to put on.
• A change of clothes for the day following surgery. Make sure these have elasticated waistbands and will not dig into the area where the bone will be taken from their hip.
• Their washbag and toiletries, including a soft toothbrush, toothpaste and soap.
• Things to play with or do, including books, magazines or games.
• A favourite toy, blanket or other anything else which might help them feel more settled on the ward.

Your appointment letter will have all the information you need, such as where to go and who to call if there are any issues.

It will also explain what time your child needs to stop eating and drinking before their surgery. This is called fasting, or ‘nil by mouth’. It’s important that your child follows these instructions exactly, as it can be dangerous if their stomach is not empty when they go in for their operation. If you have any concerns about this, make sure you raise it with your Cleft Team in advance, or the surgical team on the day.

An Alveolar Bone Graft operation is done under general anaesthetic. Your child will be completely asleep during the entire surgery and won’t feel or remember anything.

The anaesthetist usually gives the anaesthetic through a cannula (a small tube) in the back of your child’s hand. Numbing cream can be put on the back of the hand so they don’t feel anything when the tube is put in.

Anaesthetic can also be given by breathing gas and air through a mask.

You’ll be able to stay with your child while they are receiving the anaesthetic.

If you or your child have any concerns about this process, speak up a the pre-surgical appointment, or on the morning of the operation. The anaesthetist may be able to make some changes to help with nerves, such as cutting down on the number of people who need to be in the room when your child is being put to sleep, or allowing them to listen to music while it’s happening. They want to help you and your child feel as comfortable as possible with the operation, so while it’s not always possible to make changes like this, it’s always worth asking about it.

The surgeon will make a small cut (about four to six cm) in your child’s hip (‘iliac crest’) to take some soft bone tissue. Sometimes, the bone is taken from their shin (‘tibia’) instead.

A window is made in the outer surface of the bone and the inner marrow bone is scooped out. This is usually about the size of a 10p coin, but can vary. This cut is then closed and stitched up. The bone marrow will eventually grow back and the bone will be good as new.

The mucosa (red tissue covering the gum) is then opened up to expose the gap in the alveolus (bone in the gum).

The surgeon will make a ‘pocket’ with the mucosa from each side, and the bone marrow will be packed into it so the whole gap is filled. The mucosa is then stitched closed.

The operation takes around two to three hours, but your child might be ‘away’ from you for a little longer. A nurse on the ward where your child will be staying will ask for your phone number and will call you when they’re in the recovery room.

When your child wakes up, they’ll probably feel very drowsy. Their mouth and hip will feel numb and they’ll have stitches in their mouth and a sticky plaster on their hip.

There will probably be some swelling and bruising on their lip, cheek, and possibly hip. This might get worse before it gets better, but will settle down after a few days.

They’ll be given painkillers to manage any discomfort. They might have a sore throat or feel sick when they wake up, but this should settle soon. If they’re still in pain, a doctor or nurse will be able to help.

They can have a drink straight away, and start to eat soft foods whenever they are ready.

Usually, your child will need to come into the hospital early in the morning on the day of their operation. They will meet the surgeon who is doing the operation in the morning, as well as the anaesthetist and nurses who will be looking after them.

In some cases, your child will be able to go home the same day.

In other cases, they may need to stay in hospital for one night after the operation and go home the next day, as long as they feel well enough. If you live a long distance from the hospital, you might decide to stay nearby for the night before the operation.

If they need to stay overnight, one parent or carer can usually stay next to the child’s bed. The hospital ward will have visiting hours for more family or friends to visit during the day.

The Cleft Team will give you advice on how long your child needs to rest and any activities they should avoid.

The hospital will recommend regular painkillers so they are as comfortable as possible.

They may also be given antibiotics to take at home, and it is important the course of antibiotics is completed.

The Cleft Team will give advice on this. It’s important to follow this advice closely to avoid infection and give the bone graft the best chance to heal well.

They need to brush all their teeth twice a day with a soft toothbrush and adult toothpaste. You might be advised to give them mouthwash and to gargle with salt water for a time; this helps to keep the mouth clean.

The Cleft Team should also talk to your child about the stitches in their mouth and what will happen to them. Most of the time these are ‘dissolvable’, meaning they break up by themselves, but this can sometimes mean your child will spit out small pieces of the stitches when cleaning their teeth, so it’s good to prepare them for this.

Your child’s hip may have a large waterproof plaster on it when they leave hospital. The stitches used, like the ones in the mouth, will dissolve on their own and can take a couple of weeks. It’s important to keep the wound covered for the first week to keep it dry and help it heal; the Cleft Team will give advice on washing and keeping the wound dry.

There will be a small scar in an area usually covered by a swimming costume. This will fade over time.

It is important to stick to a soft diet followed by a drink of water for at least two weeks after the operation, to help the mouth to heal.

Depending on how they are recovering, they may need to keep eating softer foods for a little while longer. You may want to talk to your child’s school about ensuring appropriate food is available during lunchtimes when they return to school.

They should avoid hard foods such as toast, biscuits, crisps, or anything that might disturb the bone graft, and instead have soft foods such as soups and mashed potato.

The cleft team can advise on the best things to eat and drink after the operation. Our Children and Young People’s Council listed these as their favourite soft foods after operations:

• Mashed potato
• Yoghurt
• Custard
• Eggs (e.g. omelettes)
• Smoothies
• Fruit puree
• Blended meals
• Ice cream

Everyone is different, but it typically takes around two weeks for children to recover enough to return to school.

During the first week in particular, it’s important that they get as much rest as possible and don’t try to do too much.

During the second week, they can slowly increase their activity levels to prepare for their return to school, and may be able to catch up on some school work from home if they’re feeling well enough.

Their hip will feel stiff and sore for a little while after the operation.

It’s usually advised that they do not do physical or contact sports for at least six weeks after the operation so that the hip can recover and become strong again. This includes most PE lessons.

If there’s a particular sport or activity they do regularly, talk to your Cleft Team to see how long it will take before they can get back to this.

Every child is different and will heal at different rates, so even if the ‘minimum’ recovery time is passed, it’s important to review how your child is feeling and to seek advice from the Cleft Team if you have any concerns about them starting up sports or PE again.

The operation will leave a wound in your child’s mouth which can get infected. You can reduce the chances of this happening by keeping their mouth as clean as possible after surgery and following other instructions from the Cleft Team.

The wound might be infected if it looks redder and more swollen; a bad smell is coming from the mouth; an increase in temperature, loss of appetite, and/or your child feeling much more poorly than expected.

If any of these happen, let your Cleft Team know right away. You can also call NHS 111 for out-of-hours advice, or 999 in an emergency.

Most patients find the operation site in the mouth heals well and causes few problems. However, the hip can be sore for a few weeks after the operation. Very rarely, there can be numbness over the side of the leg where the bone graft was taken, but this usually gets better before too long.

Sometimes there can be a small gum swelling over the graft in the mouth which is a healing reaction. Your child’s Cleft Team will follow this up with them in the clinic.

The Cleft Team will schedule a follow-up appointment for around two weeks after the operation. They will check on your child’s progress and explain any next steps. They will take an x-ray of the gum area to check the ABG has healed a few months after the operation.

Further appointments will usually be made with the orthodontist, who will discuss any further treatment needed (such as braces) while the teeth erupt into the graft.

In some cases, the restorative dental team will talk to you and your child about dental implants or other treatments if there are missing teeth.

After the bone graft, the adult teeth around the cleft can take a year or longer to erupt into the mouth.

Your child’s orthodontist will check on these teeth, and may take updated x-rays around six months after the surgery to keep an eye on them.

ABG operations have a success rate of over 90%. If the mouth is kept clean and other recovery instructions are followed, it’s very likely the operation will be a success.

Sometimes, the outcome of the ABG operation isn’t as expected, and this can be for lots of reasons. If this happens, your child might need one or more ‘top-up’ bone grafts to ensure there’s enough bone in their gum for their adult teeth to be strong and secure.

It’s a good idea to talk to your child about the operation to understand anything they may be worried or uncertain about. You can make a list of questions together, and reassure them that you’ll get answers at their appointment.

Some questions you might want to ask include:

• For how long will they need to stay in hospital?
• Will any baby teeth be removed?
• What will their mouth look like after the operation?
• How soon can they get back to any hobbies or sports?

Reassure them that it’s very normal to be nervous, and encourage them to talk to you about any questions or worries they may have. If you don’t know the answers, the Cleft Team will be happy to help.

You might want to make a list of questions together and go through these at any pre-surgery appointments with the Cleft Team, or e-mail them to the surgeon or orthodontist in between appointments.

You will usually be able to make one or more appointments with the Clinical Psychologist in the Cleft Team if needed. They can help your child to open up about any worries they may have and advise on coping mechanisms and other steps you can take.

The Cleft Team want to do everything they can to make your child feel as comfortable as possible. The hospital ward may also have play specialists to help them stay calm in the hospital – these are particularly helpful for any child who is extremely nervous or has additional needs.

Information aimed at children and young people

CLAPA has information about the ABG which has been created with young people in mind.

You may also want to watch the below video from the Spires Cleft Service on the ABG operation, this video from the South West Cleft Service, or this video from Great Ormond Street Hospital.

If your child is worried about the hospital itself, you may be able to arrange a visit before the surgery so they can see where they’ll be staying and meet some of the people who will be looking after them. This can be especially helpful if you’ve been told that they will need to stay overnight, as sleeping in an unfamiliar place can be daunting.

Some children’s hospitals will have virtual tours or other resources which can help to put your child at ease. Check the hospital’s website or get in touch with them directly to see what’s available.

‘What? Why? Children in Hospital‘ has a series of excellent videos to help prepare children and their families for procedures and hospital stays, such as this one entitled ‘How do I prepare my child for hospital?‘