Faculty Files Figure 3. Eruption of the canine into a narrow graft. (A) Occlusal radiograph showing pre-eruption position. (B) Eruption into the narrow bone graft. (C) Follicular cyst at the forefront of the erupting canine, which is widening the graft to the dimensions of the crown. Canine eruption into a cleft site can widen the dimensions of graft and replace the porosities with bone from dental eruption. (D) The two-dimensional occlusal radiograph does not capture the buccopalatal narrowing of a bone graft, which appears to have good height and anteroposterior dimensions. In larger edentulous grafts, the dentally unsupported graft will continue to atrophy during adolescence enough bone for incisor eruption and root formation. It will also identify missing lateral incisors and anatomic positions of the developing teeth in the segments as well as the presence of supernumerary teeth and microdonts (Figure 2). If there is dental crowding in the premaxillary region, then we would consider early bone grafting for the same reason that the graft is performed for the canine-to provide bone for the incisor eruption. Early bone grafting is believed to enhance the periodontal prognosis of cleft-adjacent teeth. The earlier timing of the bone graft is not new. Dr. Boyne, in his early articles on the secondary bone graft,2 with great foresight wrote that craniofacial teams should consider placing the bone graft at age 7 years, before incisor eruption. This timing would be considered by most teams to be an early secondary bone graft.9 The current evidence suggests that grafts done at 6 years of age compare favorably with conventional grafts at age 10 years in terms of facial growth.10 Primary Teeth in the Cleft Site Primary teeth in the cleft site are removed at least four weeks before the bone graft surgery to allow enough time for mucosal healing. A straight suture line is needed to close the soft tissue flaps to prevent saliva with oral bacteria from entering the cleft space, causing an infection. If teeth are extracted at the same time as the surgery, then a fresh round wound in the suture line may prevent the ideal closure of the surgical flaps. An inadequate seal could 66 PCSO Bulletin Summer 2023