Purpose: Patients with maxillary clefts undergo alveolar bone grafting (ABG) between ages 6 and 12 years to stabilize the maxilla, close oronasal fistulas, and provide structure for soft tissues. ABG in older patients may be associated with poor wound healing, graft exposure, recurrent fistula, and failure of tooth eruption. A new procedure using BMP-2 on a resorbable matrix was compared to traditional iliac graft to close alveolar defects in older patients.
Methods: Skeletally mature cleft patients undergoing alveolar cleft repair were divided into two groups, Group 1: BMP-2 (experimental) or Group 2: traditional iliac graft (control) (n=21). Outcomes for bone healing were analyzed with intraoral examination and New Tom scans (3D, panorex, periapical films). The outlines of one-millimeter axial sections of the alveolar defect were used to determine the preoperative defect, postoperative defect and volume of bone fill obtained. Donor site morbidity was assessed with pain evaluation surveys based on two standard Visual Analog Scale (VAS) scores. Overall cost and length of hospital stay were used to examine economic differences.
Results: Complications: Preoperative, postoperative (6 weeks) and follow-up (1 year) intraoral examinations revealed more complications in Group 2: Traditional iliac graft compared to Group 1: BMP-2. Five out of 12 patients in Group 2 experienced partial loss of bone graft and 1/12 suffered near complete loss of bone graft secondary to wound breakdown and problematic healing. Three out of 12 developed an oronasal fistula by 6 weeks postoperatively. By comparison, in Group 1: BMP-2, only 1 of 9 patients experienced prolonged wound healing and granulation, no patients had partial or total loss of graft and none developed an oronasal fistula by 6 weeks postoperatively. No patients in either group had signs of ectopic bone formation. Bone healing: Group 1: BMP-2 showed higher grades with regard to estimated graft take than Group 2: Traditional iliac graft (2.8 + 0.2 vs. 1.9 + 0.4, p<0.05) but both groups had similar results with regard to alar base support. Panorex and 3D-CT scan readings showed enhanced mineralization in Group 1: BMP-2 (2.9 + 0.3) compared to Group 2: Traditional iliac graft (2.0 + 0.4), (p<0.05). Volumetric analysis showed Group 1: BMP-2 had a larger percent alveolar defect filled with new bone (95%) compared to Group 2: Traditional iliac graft (63%) (p<0.01). Morbidity: 100% of patients (12/12) in Group 2 experienced pain at Day 1 postoperatively and the mean pain score was 14/20. Even at 6 months, 3 of 12 patients in Group 2 still complained of some donor site pain. No patients in Group 1: BMP-2 reported pain on postoperative Day 1 and the mean pain score was 0 at all evaluations. In Group 1: BMP-2, 7/9 patients underwent the procedure as an outpatient. All of Group 2: Traditional iliac graft patients had their procedures performed as an inpatient. The mean length of stay was greater for Group 2 patients at 1.8 + 0.8 days compared to Group 1 patients at 0.4 + 0.4. In addition, the mean overall cost of the procedure including surgeon, facility, equipment and anesthesia fees was greater in Group 2 at $21,800 compared to Group 1: $11,100.
Conclusions: For this select group of late presenting alveolar cleft patients the BMP-2 procedure resulted in improved bone healing and reduced morbidity compared to traditional iliac graft.