Autogenous Iliac Crest Versus rhBMP-2 for Alveolar Cleft Grafting: A 14-Year Single-Institution Experience

PURPOSE

This study sought to compare radiographic outcomes and resource utilization between recombinant human bone morphogenetic protein-2 (rhBMP-2) and anterior iliac crest bone graft (AICBG) when used for secondary alveolar grafting.

MATERIALS AND METHODS

This is a 14-year retrospective study of patients with alveolar clefts treated at the Morgan Stanley Children's Hospital of New York-Presbyterian/Columbia University Irving Medical Center between January 2006 and January 2020. Patients who had alveolar grafting with either rhBMP-2 or AICBG were included in this study. The primary study predictor was the graft material. The study outcomes were bone height, operating room time, and the number of scrubbed personnel (surgeon and assistants). Graft survival was measured at a minimum of 6 months postoperatively. Bone height was scored according to the Bergland scale, and radiographic success was defined as Bergland types 1 or 2.

RESULTS

The study sample included a total of 115 patients with 130 alveolar clefts. Overall, 13.0% of patients had bilateral repairs, and 17.4% were retreatments. The cumulative success rate was 89.5%. There were no differences in success between materials (rhBMP: 90.3%; AICBG: 89.1%; P = .85). Patients presenting for retreatment were more likely to receive rhBMP-2 than AICBG (48.6 vs 3.8%, P < .01). After controlling for other significant confounders, the rhBMP-2 group required less personnel (P < .01) and operating room time (P < .01). Only 1 patient in the rhBMP-2 group was admitted, whereas all AICBG patients were admitted a minimum of 1 night.

CONCLUSIONS

Compared with AICBG, rhBMP-2 produced a similar height of bone but required less hospital resources. The decision to use harvested ilium or rhBMP-2 is not limited by outcome data at this time. More studies will need to be performed to identify the particular advantages of each graft material. The choice of material is currently both surgeon specific and patient specific and requires thorough informed consent.

Using 3D computer planning for complex reconstruction of mandibular defects

For complex reconstruction of osseous defects of the head and neck, three-dimensional (3D) computer planning has been available for over 20 years. However, despite its availability and recent refinements, it is a technology that has not been widely adopted. While 3D computer planning has been proposed to improve surgical precision, reduce operating time and enhance functional outcomes, the objective evidence supporting these claims is limited. Here we review the recent literature that supports the use of 3D computer planning for complex osseous defects of the mandible. We highlight a case example where 3D modeling played a critical role, particularly during the virtual surgical planning stage. Finally, we propose that routine post-operative 3D analysis become an essential element in determining operative success. Critical evaluation of outcomes will better define its use in complex reconstruction of osseous defects.

Maxillary sinus bone augmentation techniques

Maxillary sinus expansion and atrophy can be difficult to overcome for patients who require functional dental prostheses. One solution for this problem is sinus augmentation and implant placement. Patients are evaluated and diagnosis is ascertained, leading to development of a treatment plan and surgical strategy. The surgeon decides on a surgical technique and grafting material, based on ultimate success, stability, and function as they relate to the goals. Complications can occur during an operation or during the postoperative healing phase. Dealing with these complications can be challenging; however, solving these problems positively affects the overall outcome and success.

Resection of an upper cervical aneurysmal bone cyst and spinal reconstruction using a midline mandibular osteotomy in a pediatric patient

The authors report on the surgical management of an extensive lesion of the upper cervical spine that required an uncommon transmandibular approach to facilitate exposure, resection, and stabilization in a pediatric patient. A 6-year-old boy with a large aneurysmal bone cyst of the C-2 vertebra presented with progressive weakness and right-sided neck pain. The lesion extended laterally into the soft tissue of the neck, inferiorly to C-4, and posteriorly around the spinal cord. A transmandibular osteotomy was performed to provide adequate exposure for complete resection of the mass and anterior C1-3 instrumentation and fusion. Subsequently, the patient underwent occiput to C-4 posterior instrumentation and fusion. The patient tolerated the operation well and had regained all function at 3 and 11 months' follow-up. No neurological complications or problems of speech, swallowing, or respiration occurred. Even in pediatric patients, the transmandibular approach for the treatment of upper cervical spine lesions is an effective method of maximizing exposure for complex lesions requiring resection and stabilization.