Three-Dimensional Upper Lip and Nostril Sill Changes After Cleft Alveolus Reconstruction Using Autologous Bone Grafting Versus Recombinant Human Bone Morphogenetic Protein-2 :

The management of alveolar clefts has changed through the years as medical knowledge has improved. An alveolar cleft is the result of abnormal primary palate formation during weeks 4 to 12 of gestation. The rationale for its closure includes 1) stabilizing the maxillary arch, 2) permitting support for tooth eruption, 3) eliminating oronasal fistulae, and 4) providing improved esthetic results. Methods for closure of the alveolar cleft have been solidified during the last century with the use of bone grafting. Secondary bone grafting is now the preferred method of treatment, because early grafting has proven detrimental to midfacial growth. Various materials for bone grafting have been proposed, including iliac crest, cranium, tibia, rib, and mandibular symphysis. Regardless of the timing and materials used, the main principles in approaching alveolar clefts have been well described. They include 1) appropriate flap design, 2) wide exposure, 3) nasal floor reconstruction, 4) closure of oronasal fistula, 5) packing bony defect with cancellous bone, and 6) coverage of bone graft with gingival mucoperiosteal flaps. Certain alveolar clefts are difficult to manage by grafting alone, and orthodontic preparation may be required. Complications of alveolar bone grafts include donor site morbidity as well as graft exposure and loss.

The arthritic glenoid is typically in retroversion and restoration to neutral version is recommended. While a method for measurement of glenoid version using axial computed tomography (CT) has been reported and has been widely accepted, its accuracy and reproducibility has not been established. In 33 patients scheduled for shoulder arthroplasty, glenoid version and maximum wear of the glenoid articular surface were measured with respect to the scapular body axis on 2-dimensional- (2D) CT slices as well as on 3-dimensional- (3D) reconstructed models of the same CT slices. Clinical CT scans were axially aligned with the patient's torso but were almost never perpendicular to the scapular body. The average absolute error in version measured on the 2D-CT slice passing through the tip of the coracoid was 5.1 degrees (range, 0 - 16 degrees , P < .001). On high-resolution 3D-CT reconstructions, the location of maximum wear was most commonly posterior and was missed on the clinical 2D-CT slices in 52% of cases. Error in measuring version and depth of maximum wear can substantially affect the determination of the degree of correction necessary in arthritic glenoids. Accurately measuring glenoid version and locating the direction of maximum wear requires a full 3D-CT reconstruction and analysis. Copyright 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

In older cleft patients, alveolar bone grafting may be associated with poor wound healing, graft exposure, recurrent fistula, and failure of tooth eruption. A new procedure using a resorbable collagen matrix with bone morphogenetic protein (BMP)-2 was compared with traditional iliac crest bone graft to close alveolar defects in older patients. Skeletally mature patients with an alveolar cleft defect undergoing alveolar cleft repair were divided into either group 1 (BMP-2, experimental) or group 2 (traditional iliac graft, control) (n = 21). Bone healing was assessed with intraoral examination and NewTom scans (three-dimensional, Panorex, periapical films). Donor-site morbidity was determined with pain surveys. Overall cost and length of hospital stay were used to examine economic differences. Preoperative and follow-up (1 year) intraoral examinations revealed fewer complications (11 percent versus 50 percent) and better estimated bone graft take in group 1 compared with group 2. Panorex and three-dimensional computed tomographic scans showed enhanced mineralization in group 1 compared with group 2. Volumetric analysis showed group 1 had a larger percentage alveolar defect filled with new bone (95 percent) compared with group 2 (63 percent). Donor-site pain intensity and frequency were significant in group 2 but not group 1. The mean length of stay was greater for group 2 compared with group 1. In addition, the mean overall cost of the procedure was greater in group 2 ($21,800) compared with group 1 ($11,100). For this select group of late-presenting alveolar cleft patients, the BMP-2 procedure resulted in improved bone healing and reduced morbidity compared with traditional iliac bone grafting.