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Management of Failed Alveolar Bone Grafts: Increasing the Success Rate by Means of Cord Blood Transplantation Combined Allograft

Li, Cheng-hao M.D.; Huang, Ning M.D.; Liu, Ren-kai M.D.; Shi, Bing M.D., Ph.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 484e–485e
doi: 10.1097/PRS.0000000000000443
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State Key Laboratory of Oral Disease, West China College of Stomatology, and Department of Cleft Lip and Palate Surgery, West China Stomatological Hospital, Sichuan University

State Key Laboratory of Oral Disease, West China College of Stomatology, Sichuan University

State Key Laboratory of Oral Disease, West China College of Stomatology, and Department of Cleft Lip and Palate Surgery, West China Stomatological Hospital, Sichuan University, Chengdu, People’s Republic of China

Correspondence to Dr. Shi, No. 14, Section 3, Ren Min Nan Road, Chengdu 610041, People’s Republic of China, shibingcn@sina.com

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Sir:

We read with great interest the recent article “Management of Failed Alveolar Bone Grafts: Improved Outcomes and Decreased Morbidity with Allograft Alone.”1 We would like to take the opportunity to further expand on the topic of increasing the success rate of secondary alveolar bone grafting by cord blood transplantation combined allograft.

Secondary alveolar bone grafting is a well-established technique in the management of patients with cleft lip–cleft palate; any patient with a cleft should be considered for grafting. Fresh autogenous cancellous bone is ideal for secondary alveolar cleft bone grafting because it supplies living, immunocompatible bony cells that integrate fully with the maxilla and are essential for osteogenesis. According to Koberg’s and Witsenburg’s thorough reviews, alveolar grafts were first attempted in the early 1900s using bone and soft tissue from the little finger.2 A variety of different donor sites have been used since then, with the most common being from the iliac crest, calvaria, mandibular symphysis, and tibia. Evidence suggests that oronasal fistula occurrence is greatly reduced when grafts are used. Bone grafts can provide a basis for shaping a closed dental arch and a matrix for tooth eruption, and may prevent transverse collapse of the anterior maxilla. Besides establishment of maxillary arch continuity with stabilization of the osseous segments, bony support of the nose and lip further leads to restitution and improvement of facial aesthetics.3

Among a variety of different donor sites, the iliac crest remains the criterion standard for secondary alveolar bone grafting because of its accessibility, abundance of cancellous bone, and relative ease of bone harvest. Nevertheless, what remains a headache to the surgeon is the time of alveolar bone grafting. The alveolar cleft (gap in the gum) is not usually closed at the time of lip surgery during infancy, as this may affect facial growth. By contrast, it has also been shown that if the cleft is closed after the teeth have begun to erupt into the cleft, the results are poor. Thus, most surgeons feel the best time for this primary surgery on the alveolar cleft is when the permanent canine tooth is three-quarters formed, generally approximately age 8 to 9 years, because it is very important for children to have a nice smile with good straight teeth earlier, both for eating and for self-confidence. Can we attempt to close this alveolar cleft earlier, at the same time as the lip or palate surgery? Meanwhile, some authors have also suggested that the iliac crest as a donor site produces an unacceptably high degree of postoperative morbidity, such as chronic pain, disability, hemorrhage, visible scar, contour deformity, and sensory loss. How do we solve these problems at the same time? Cord blood transplantation combined allograft could indicate a new direction for this field.

Drs. Losee and Kirschner attempted to prepare the implant by soaking a Helistat-activated collagen sponge (Integra LifeSciences Corp., Plainsboro, N.J.) of preselected size with reconstructed recombinant human bone morphogenetic protein 2 applied uniformly over the Helistat-activated collagen sponge.4 The surgeons have also attempted to reduce morbidity and improve healing with mesenchymal stem cells in patients with alveolar cleft defects. Mesenchymal stem cells, which can be isolated from the marrow cavity and from the trabecular compartment, have been shown to have the ability to form new bone when transplanted. Bone marrow aspirated with resorbable collagen matrix has been reported to be associated with reduced morbidity in repair of alveolar cleft defects. Bone substitution materials can be combined with vital cells such as mesenchymal stem cells to increase bone formation. Both synthetic and allograft materials allow adhesion and growth of osteoblastic cells, or osteogenic differentiation of precursor cells in vitro.5 Recent research has shown that the addition of platelet-rich plasma appeared to provide a significant benefit to healing in the alveolar bone graft. However, we believe that cord blood shows more advantages. As we know, cord blood is a rich source of stem cells. Stem cells from cord blood offer some important advantages over those retrieved from bone marrow, such as safe, easy collection; more matches; faster availability; reduced risk of graft; and fewer infections. In addition, studies have indicated that cord blood had a greater ability to generate new blood cells than bone marrow.6

On the basis of the above facts, we believe that cord blood is what we need, so we hypothesized a possible method to close this alveolar cleft earlier and increase the success rate of secondary alveolar bone grafting by cord blood transplantation combined allograft. Based on this article, secondary alveolar bone grafting will provide a basis for shaping a closed dental arch with an intact periodontium in the cleft area earlier by cord blood transplantation combined allograft. Such dental-alveolar restoration to original condition within the cleft area, which can be achieved under optimal circumstances, provides the preconditions for creating optimal functional and aesthetic results not only with respect to chewing function, but also by natural upper lip and symmetrical nose positions.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Cheng-hao Li, M.D.

State Key Laboratory of Oral Disease

West China College of Stomatology, and Department of Cleft Lip and Palate Surgery

West China Stomatological Hospital

Sichuan University

Ning Huang, M.D.

Ren-kai Liu, M.D.

State Key Laboratory of Oral Disease

West China College of Stomatology

Sichuan University

Bing Shi, M.D., Ph.D.

State Key Laboratory of Oral Disease

West China College of Stomatology, and Department of Cleft Lip and Palate Surgery

West China Stomatological Hospital

Sichuan University

Chengdu, People’s Republic of China

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REFERENCES

1. Sivak WN, Macisaac ZM, Rottgers SA, Losee JE, Kumar AR. Management of failed alveolar bone grafts: Improved outcomes and decreased morbidity with allograft alone. Plast Reconstr Surg. 2014;133:345–354
2. Witsenburg B. The reconstruction of anterior residual bone defects in patients with cleft lip, alveolus and palate: A review. J Maxillofac Surg. 1985;13:197–208
3. Bayerlein T, Proff P, Heinrich A, Kaduk W, Hosten N, Gedrange T. Evaluation of bone availability in the cleft area following secondary osteoplasty. J Craniomaxillofac Surg. 2006;34(Suppl 2):57–61
4. Losee JE, Kirschner RE Comprehensive Cleft Care. 2008 New York McGraw-Hill Medical:260
5. Behnia H, Khojasteh A, Soleimani M, et al. Secondary repair of alveolar clefts using human mesenchymal stem cells. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:e1–e6
6. Ballen K. Introduction to cord blood special issue. Bone Marrow Transplant. 2009;44:619
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