OBJECTIVE The purpose of this study was to determine the optimal timing for placement and to evaluate short- and long-term outcomes of endosseous implants in bone-grafted alveolar clefts. METHODS Fourteen patients who underwent alveolar cleft bone grafting (ACBG) and closure of an oronasal fistula followed by restoration of the missing lateral incisor tooth using endosseous implants (EI) were studied. The oronasal fistulae were closed using local flaps, and the alveolus was grafted with fresh autogenous iliac marrow. Endosseous implants were placed a minimum of 4 months following ACBG. The average age at ACBG was 20.35 years (range, 12-65 yr), and at implant placement 22.2 years (range, 15-66 yr). It was necessary to regraft the alveolar cleft region in six patients to provide adequate bone volume for implant placement. Those who required alveolar regrafting had an increased mean interval between the initial ACBG and planned implant placement compared to the patients with adequate bone available for implant placement 26.4 months (range, 4-46 mo) versus 15.75 months (range, 4-36 mo). RESULTS Twenty-nine implants were placed in 14 patients, 9 outside of the cleft region and 20 in grafted alveolar clefts. Eighteen of 20 (90%) implants in the bone-grafted alveolar clefts have been successfully restored. The mean follow-up after implant placement was 39.1 months (range, 1-54 mo), and after restoration 28.5 months (range, 1-47 mo). CONCLUSIONS Endosseous implants can be placed in bone-grafted alveolar clefts. Consideration should be given to the adequacy of graft volume and ridge morphology at the time of ACBG. The interval between ACBG and implant placement is important. The greater the interval beyond 4 months, the more likely there will be inadequate bone volume to accept an implant.