title: rhBMP-2 with a demineralized bone matrix scaffold versus autologous iliac crest bone graft for alveolar cleft reconstruction.
abstract: BACKGROUND
  Secondary alveolar cleft reconstruction using autologous iliac crest bone graft is currently the standard treatment for alveolar clefts. Although effective, harvesting autologous bone may result in considerable donor-site morbidity, most commonly pain and the potential for long-term sensory disturbances. In an effort to decrease patient morbidity, a novel technique using recombinant human bone morphogenetic protein (rhBMP)-2 encased in a demineralized bone matrix scaffold was developed as an alternative to autografting for secondary alveolar cleft reconstruction.
  
  
  METHODS
  A chart review was conducted for the 55 patients who underwent secondary alveolar cleft reconstruction over a 2-year period with a mean follow-up of 21 months. Of these, 36 patients received rhBMP-2/demineralized bone matrix scaffold (including 10 patients with previously failed repairs using iliac crest bone grafting) and 19 patients underwent iliac crest bone grafting. Postoperatively, bone stock was evaluated using occlusal radiographs rated according to the Bergland and Chelsea scales.
  
  
  RESULTS
  Alveolar clefts repaired using rhBMP-2/demineralized bone matrix scaffold were 97.2 percent successful compared with 84.2 percent with iliac crest bone grafting. Radiographically, initial repairs with rhBMP-2/demineralized bone matrix scaffold were superior to iliac crest bone grafting according to both Bergland and Chelsea scales, and significantly more patients in the rhBMP-2/demineralized bone matrix scaffold group had coronal bridging. The postoperative intraoral infection rate following iliac crest bone grafting was significantly greater than for rhBMP-2/demineralized bone matrix scaffold. The cost of rhBMP-2/demineralized bone matrix scaffold products was offset by cost savings associated with a reduction in operative time averaging 102 minutes.
  
  
  CONCLUSIONS
  rhBMP-2 encased in a demineralized bone matrix scaffold appears to be a viable alternative for secondary alveolar cleft repair. Patients are spared donor-site morbidity and achieve excellent results, decreasing operative time, and increasing operating room use.
  
  
  METHODS
  Therapeutic, III.
authors: Los Angeles, Calif.; and Houston, Texas From the Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles; Division of Plastic and Reconstructive Surgery, University of Southern California, Keck School of Medicine; Division of Plastic and Reconstructive Surgery, University of Texas Health Science Center; and Department of Oral and Maxillofacial Surgery, University of Southern California, School of Dentistry.
authors: Cameron S
authors: CS
authors: Francis
authors: Sheila S Nazarian
authors: SSN
authors: Mobin
authors: Michael A
authors: MA
authors: Lypka
authors: Elizabeth
authors: E
authors: Rommer
authors: Stephen
authors: S
authors: Yen
authors: Mark M
authors: MM
authors: Urata
authors: Jeffrey A
authors: JA
authors: Hammoudeh
mesh_terms: D000293:Adolescent; D018775:Bone Demineralization Technique / Q000379:methods*; D055396:Bone Morphogenetic Protein 2 / Q000627:therapeutic use*; D016025:Bone Transplantation / Q000379:methods*; D002648:Child; D002971:Cleft Lip / Q000000981:diagnostic imaging / Q000601:surgery*; D002972:Cleft Palate / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007085:Ilium / Q000637:transplantation*; D008297:Male; D009017:Morbidity; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control; D011859:Radiography; D011994:Recombinant Proteins / Q000627:therapeutic use; D019651:Plastic Surgery Procedures / Q000379:methods; D012189:Retrospective Studies; D054457:Tissue Scaffolds
chemical_list: C525718:BMP2 protein, human; D055396:Bone Morphogenetic Protein 2; D011994:Recombinant Proteins
references: Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg. 1972;30:87–92
references: Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J. 1986;23:175–205
references: Berkowitz S. Gingivoperiosteoplasty as well as early palatal cleft closure is unproductive. J Craniofac Surg. 2009;20(Suppl 2):1747–1758
references: Jia YL, Fu MK, Ma L. Long-term outcome of secondary alveolar bone grafting in patients with various types of cleft. Br J Oral Maxillofac Surg. 2006;44:308–312
references: Horswell BB, Henderson JM. Secondary osteoplasty of the alveolar cleft defect. J Oral Maxillofac Surg. 2003;61:1082–1090
references: Laurie SW, Kaban LB, Mulliken JB, Murray JE. Donor-site morbidity after harvesting rib and iliac bone. Plast Reconstr Surg. 1984;73:933–938
references: Dickinson BP, Ashley RK, Wasson KL, et al. Reduced morbidity and improved healing with bone morphogenic protein-2 in older patients with alveolar cleft defects. Plast Reconstr Surg. 2008;121:209–217
references: Chin M, Ng T, Tom WK, Carstens M. Repair of alveolar clefts with recombinant human bone morphogenetic protein (rhBMP-2) in patients with clefts. J Craniofac Surg. 2005;16:778–789
references: Herford AS, Boyne PJ, Rawson R, Williams RP. Bone morphogenetic protein-induced repair of the premaxillary cleft. J Oral Maxillofac Surg. 2007;65:2136–2141
references: Chin M. Primary reconstruction of alveolar clefts using recombinant human bone morphogenetic protein-2: Clinical and radiologic outcomes. J Craniofac Surg. 2009;20(Suppl 2):1766–1767
references: Fallucco MA, Carstens MH. Primary reconstruction of alveolar clefts using recombinant human bone morphogenic protein-2: Clinical and radiographic outcomes. J Craniofac Surg. 2009;20(Suppl 2):1759–1764
references: Witherow H, Cox S, Jones E, Carr R, Waterhouse N. A new scale to assess radiographic success of secondary alveolar bone grafts. Cleft Palate Craniofac J. 2002;39:255–260
references: Murthy AS, Lehman JA. Evaluation of alveolar bone grafting: A survey of ACPA teams. Cleft Palate Craniofac J. 2005;42:99–101
references: Rosenstein SW, Monroe CW, Kernahan DA, Jacobson BN, Griffith BH, Bauer BS. The case of early bone grafting in cleft lip and cleft palate. Plast Reconstr Surg. 1982;70:297–309
references: Friede H, Johanson B. A follow-up study of cleft children treated with primary bone grafting: 1. Orthodontic aspects. Scand J Plast Reconstr Surg. 1974;8:88–103
references: Millard DR Jr, Latham RA. Improved primary surgical and dental treatment of clefts. Plast Reconstr Surg. 1990;86:856–871
references: Santiago PE, Grayson BH, Cutting CB, Gianoutsos MP, Brecht LE, Kwon SM. Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperiosteoplasty. Cleft Palate Craniofac J. 1998;35:77–80
references: Akamaru T, Suh D, Boden SD, Kim HS, Minamide A, Louis-Ugbo J. Simple carrier matrix modifications can enhance delivery of recombinant human bone morphogenetic protein-2 for posterolateral spine fusion. Spine. 2003;28:429–434
references: Martin GJ Jr, Boden SD, Marone MA, Marone MA, Moskovitz PA. Posterolateral intertransverse process spinal arthrodesis with rhBMP-2 in a nonhuman primate: Important lessons learned regarding dose, carrier, and safety. J Spinal Disord. 1999;12:179–186
references: Herford AS, Lu M, Buxton AN, et al. Recombinant human bone morphogenetic protein 2 combined with an osteoconductive bulking agent for mandibular continuity defects in nonhuman primates. J Oral Maxillofac Surg. 2012;70:703–716
references: Dawson E, Bae HW, Burkus JK, Stambough JL, Glassman SD. Recombinant human bone morphogenetic protein-2 on an absorbable collagen sponge with an osteoconductive bulking agent in posterolateral arthrodesis with instrumentation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91:1604–1613
references: Barnes B, Boden SD, Louis-Ugbo J, et al. Lower dose of rhBMP-2 achieves spine fusion when combined with an osteoconductive bulking agent in non-human primates. Spine. 2005;30:1127–1133
references: Goudy S, Lott D, Burton R, Wheeler J, Canady J. Secondary alveolar bone grafting: Outcomes, revisions, and new applications. Cleft Palate Craniofac J. 2009;46:610–612
references: Almasri M. Reconstruction of the alveolar cleft: Effect of preoperative extraction of deciduous teeth at the sites of clefts on the incidence of postoperative complications. Br J Oral Maxillofac Surg. 2012;50:154–156
references: Johanson B, Ohlsson A, Friede H, Ahlgren J. A follow-up study of cleft lip and palate patients treated with orthodontics, secondary bone grafting, and prosthetic rehabilitation. Scand J Plast Reconstr Surg. 1974;8:121–135