Decreased Secondary Bone Grafting but poorer midface growth after Primary Alveolar Cleft Repair with Gingivoperiosteoplasty and rhBMP-2
Kristen S. Yee, MD, Phuong D. Nguyen, MD, Brian T. Andrews, MD, Justine C. Lee, MD, PhD, James P. Bradley, MD.
University of California Los Angeles, Los Angeles, CA, USA.
Studies from NYU revealed that following nasoalveolar molding/gingivoperiosteoplasty (GPP) 60% of patients did not require an alveolar bone graft. In our lab midface animal growth was not detrimentally affected after BMP-2 healing of alveolar clefts. In this study, we performed a similar procedure to NYU with alveolar molding/GPP but with BMP-2 on a resorbable matrix for primary alveolar repair in the infant. We compared long-term follow-up (10 years) for 1) No GPP, 2) GPP only or 2) GPP with BMP-2 by analyzing alveolar bone, tooth eruption, and maxillary growth.
For the three primary unilateral cleft repair patient groups: 1) No GPP (n=15), 2) GPP only (n=15) or 2) GPP with BMP-2 (n=10) we performed follow-up studies at least 10 years after the procedure. There was one GPP patient lost to follow-up. We recorded need for secondary alveolar bone grafting, timing of tooth eruption, and clinical evidence of maxillary hypoplasia. New-Tom scans were used to analyze dentition, bone volume and bone density.
For dentition, there was absent cleft lateral incisor in 40% of patient (40%, 46% 50%). Cleft site secondary tooth eruption was variable but occurred at a mean of 1.8+0.4 years earlier in 2) GPP and 3) GPP/BMP-2 compared to 1) No GPP. Greater bone graft volume/density was seen at the cleft site in the 3) GPP/BMP compared to the 2) GPP only (86% vs 42% bone fill). Secondary alveolar bone grafting after expansion was necessary in 1) ‘No GPP’ patients (100%); 2) ‘GPP only’ (73%); 3) ‘GPP/BMP-2’ (20%). Bone volume Two patient in GPP/BMP-2 underwent Le Fort I distraction at age 13. In the other groups there were no patients, to date, who undergone Le Fort I distraction. Clinical evidence of maxillary hypoplasia was seen in 1) ‘No GPP’ patients (40%); 2) ‘GPP only’ (53%); 3) ‘GPP/BMP’ (60%). We are in the process of collecting and recording our lateral cephalogram data.
In a long-term follow-up, after mid-childhood but prior to skeletal maturity, GPP/BMP-2 primary alveolar cleft repairs showed similar tooth eruption, improved bone fill of the cleft site, less need for secondary alveolar grafting. However, data thus far shows poorer midface growth compared to No GPP at primary cleft repair.
This study documents our group’s IRB approved study primary alveolar clefts with the use of gingivoperiosteoplasty, BMP-2 and a collagen scaffold as an alternative technique to traditional care.
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