Discussion
Secondary alveolar cleft, MPM, alveolar cleft, oronasal fistula, cleft teeth
CLOT, CREST, ERUPTION
Secondary alveolar cleft grafting aims to create a bone bridge connecting the two maxillary bony segments and hence stabilizing the maxillary arch, closure of oronasal fistula and to create a sound bone foundation for the future eruption of the cleft teeth and/or for implant replacement of missing cleft teeth.Autogenous cancellous bone graft harvested from the anterior iliac crest is considered the “gold standard” for alveolar cleft reconstruction as it is easy to access, offers large quantities of autogenous bone which contain large amount of osteogenic cells that promote osteogenesis, and it has osteo-inductive capability as it contains viable cells and growth factors that ensure total consolidation and incorporation with the surrounding maxillary bone, but the lack of positional stability and the subsequent high resorption rate of the iliac spongiosa decrease its bone grafting quality and might result in the need for another grafting maneuver [To improve the bone grafting outcome, a number of qualities need to be enhanced, like space maintenance, scaffolding, and the stability of the graft. Mineralized plasmatic matrix (MPM) preparation shows the simplicity of the PRF protocol while yielding a liquid platelet/fibrin concentrate that can bind to bone, and it is the only natural and autogenous product that offers stability to the bone chips and this offers the mouldability and positional stability through chemical stabilization of the bone graft and preservation of its shape with subsequent “in situ” immobilization.The MPM is prepared by centrifugation of collected autogenous blood samples using plain tubes without neither anticoagulant or clot activator. At the end of the centrifugation, the superior liquid part of the tube contains fibrinogen, platelets, and monocytes. This liquid will be collected and added to the autogenous bone graft chips, once this plasma is in contact with the bone graft, the activation will start and the fibrinogen will transform into the fibrin network.This graft manipulation is very important because it induces physical changes to the harvested bone particles to become homogenous, easy-to-handle, and of moldable consistency in addition to bio-chemical changes as it enriches the graft with the fibrin that acts as fibrin glue and by that, the whole mass of the MPM graft becomes moldable and stable in place. In addition to that, the MPM contains cells such as platelets which add growth factors and cytokines in addition to monocytes that play an important role in the regulation of the natural bone morphogenic protein (BMP). Thus MPM, based on its structure, should be considered whenever a bone grafting procedure is attempted [Similar to the results of the current study, Marukawa et al. (2011) found that the use of PRP yielded better results for decreasing the resorption of the height and width of the bone graft as compared to autogenous cancellous bone alone [Based on the literature, authors believed that the MPM offered stability for the graft as MPM contains platelets and fibrin concentrate in a liquid state; these materials can harden and bound to bone particles giving a moldable bone mass that was easy to shape which is responsible for graft height and width stability over time, So the 6-month outcomes of MPM were excellent regarding bone graft stability that was reflected positively in term of maintained graft bone width and height. On the other hand, the control group bone particulates stability is highly affected by the chewing forces, food impinging over the overlying mucosa and the movement of the constricted and scarred lip in some patients which results in reduced graft height and width after a period of time as it lakes the main cause for graft success which is graft stability. Also, the percentage of bone volume changes showed that graft instability in the control group led to reduction of 48.9% of graft volume, while in the MPM group, the reduction of graft volume was limited to 19.6% owing to the graft stability that support the actual mechanism of the MPM grafting technique also the enriched growth factors that limit the graft resorption and enhanced its consolidation reflected positively in term of maintained graft volume width and height [The most important advantage of the MPM — against the gold standard procedure — is the incorporation of bone graft particles inside the fibrin network, which grants the MPM positional stability by stabilizing the bone particles, preserving their shape and volume with subsequent “in situ” immobilization of the components of grafting materials [