Bone grafting of the alveolus has become an essential part of the contemporary surgical management of cleft deformities. While the concept of grafting of the cleft maxilla was introduced in the early 1900s, it was not widely recognized until a half century later. Beginning in 1955, successful cortical grafting of maxillary clefts in both infancy and later childhood was reported in Europe. Since then, alveolar cleft grafting has continued to grow in both popularity and success and is now generally acknowledged to be integral to the management of the cleft patient. The benefits and goals of this procedure are well understood and include the stabilization of the maxillary arch, elimination of oronasal fistulae, creation of bony support for subsequent tooth eruption, and reconstruction of the hypoplastic pyriform aperture and soft tissue nasal base support. There are different techniques and philosophies involved in alveolar bone grafting, but secondary grafting with iliac marrow is the current gold standard. It requires good orthodontic work-up, meticulous planning and preoperative arch alignment. Its high success rate currently makes it the most practised method. The scope of this chapter is to discuss the management of the alveolar cleft in general and the technique of secondary alveolar bone grafting, advances and complications associated with it.