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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 73-77

Implant rehabilitation in cleft patients: A retrospective study in our center


Department of Maxillofacial Surgery, University Hospital A Coruña, La Coruña, Spain

Date of Web Publication21-Nov-2017

Correspondence Address:
José-Luis López-Cedrún Cembranos
Department of Maxillofacial Surgery, University Hospital A Coruña, La Coruña, Calle Las Jubias S/N. 15006 La Coruña
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_74_17

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  Abstract 

Introduction: One of the objectives of alveoloplasty and alveolar bone grafting is to create a stable and continuous maxillary arch that allows teeth eruption through the bone graft. The dental rehabilitation by means of implants is a good technique for prosthodontic rehabilitation of edentulous space in cleft patients. The aim of this study is to review our series of patients with clefts rehabilitated with dental implants. Materials and Methods: A retrospective study of 25 patients treated by means a dental rehabilitation based in implants has been realized. We have evaluated the type of alveoloplasty, the age of the patient at the time of implant insertion, the success of the procedure and the need of additional techniques before or at the time of the procedure. Results: Before the insertion of implants, 11 patients had received a secondary alveoloplasty, 10 patients a late alveoloplasty, and four patients did not received an alveoloplasty procedure. A total of 47 implants have been inserted. The mean follow-up ranged between 6 and 153 months. No implants were lost in this period. The mean age of insertion of implants varies regarding the type of alveoloplasty. Four patients needed a bone block graft before the implant insertion, one was treated with a sinus lift, and nine patients received a supplement of bone at the time of insertion of the implant. Conclusions: Dental rehabilitation with implants is a safe procedure to close the edentulous gap in cleft patients.

Keywords: Alveoloplasty, cleft palate, dental implants


How to cite this article:
Cembranos JLL, Neagu D, Rey RL, Castro MJ, Mourelle AG, Prieto FG. Implant rehabilitation in cleft patients: A retrospective study in our center. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:73-7

How to cite this URL:
Cembranos JLL, Neagu D, Rey RL, Castro MJ, Mourelle AG, Prieto FG. Implant rehabilitation in cleft patients: A retrospective study in our center. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:73-7. Available from: https://www.jclpca.org/text.asp?2017/4/3/73/218891


  Introduction Top


The rehabilitation of edentulous space in patients with cleft palate can be carried out through orthodontic treatment, dental space preservation with prosthetic placement, or orthognatic surgery.

Alveoloplasty allows stable and continuous maxillary arch, and it still represents a suitable surgical technique for cleft palate pathology.[1],[2],[3],[4] The dental rehabilitation by means of implants is a good technique for closing the edentulous gap in cleft patients.[5],[6],[7],[8],[9],[10],[11],[12],[13]

The aim of this study is to review our series of patients with clefts rehabilitated with dental implants.


  Materials and Methods Top


A retrospective study of 25 patients (28 clefts) was performed. Eleven patients had a left cleft lip and palate, 9 patients had a right cleft lip and palate, and 4 had a bilateral cleft lip and palate deformity. We included a patient with a cleft palate and right lateral incisor, as we considered a good case for dental rehabilitation, although the case does not present an alveolar cleft. Patients were treated by means of a dental rehabilitation based in implants, with a follow-up from 6 to 153 months. Fourteen patients (56%) were female and 11 (44%) were male. The demographic variables are shown in [Figure 1].
Figure 1: Diagram showing the type of cleft palate and the type of alveoloplasty performed in our series.*GBR: Guided bone regeneration

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A total of 47 dental implants (SLActive, Straumann©, Basel, Switzerland) were inserted. Dental rehabilitation was carried out with fixed prosthesis in all cases.

We have studied factors related to implant insertion and survival: type of alveoloplasty (secondary or late), time from alveoloplasty to implant insertion (in months), need of regrafting, type of graft used, timing of regrafting (simultaneous with implant insertion or delayed), and implant success in terms of survival.


  Results Top


According with our treatment protocol, a Millard cheiloplasty and a Veau-Wardill-Kilner or Von Langenbeck palatoplasty was performed. The secondary alveoloplasty procedure and alveolar bone grafting at the time of mixed dentition was carried out in patients with an alveolar cleft. In this series of rehabilitated patients with implants, 12 secondary alveoloplasties were performed in 11 patients and 12 late alveoloplasties were performed in 10 patients. We decided to perform a distraction osteogenesis procedure (by means of transport of a bone disc adjacent to the alveolar cleft) in two adult patients because of the poor periodontal conditions and scar formation due to the previous surgeries. In these cases, a Liou© (KLS-Martin©, Tuttlingen, Germany) device was used, with a horizontal vector. In one of them, two microscrews (one on the buccal bone table and one in the palatal table of the maxillary bone) were inserted to help in the control of the vector direction.

Two adult patients did not receive any alveoloplasty procedure (one of them without an alveolar cleft – which was included as the right lateral incisor agenesis was treated by dental implant – and another patient treated by means of a bilateral sinus lift procedure without closing the alveolar clefts). The mean age of patients at the time of implant insertion varies regarding the type of alveoloplasty: In the secondary alveoloplasty group was 17.5 years (ranging from 14 to 23 years) and 27.3 years (ranging from 16 to 47 years) in the late alveoloplasty group, with a mean age of dental implant procedure of the global sample of 24 years.

The lapse of time from alveoloplasty to implant surgery also varied according to the type of alveoloplasty: In secondary alveoloplasty group, the implant insertion procedure was performed after an average lapse of time of 102.3 and 25.2 months in the late alveoloplasty group. The time between mixed dentition and complete dentofacial development leads to a delay in dental implant rehabilitation that often results in bone resorption requiring further treatment.

Thirteen patients requiring alveoloplasty (from a global sample of 21 patients – excluding distraction cases, bilateral sinus lift case and palate cleft palate) needed a regrafting procedure at the time or before the implant insertion. In nine patients, guided bone regeneration (GBR) was carried out with supplement of bone at the time of insertion of the implant (six patients in the secondary alveoloplasty group and three patients in the late alveoloplasty group) [Figure 1]. Materials used were DBX© demineralized bone matrix (DePuy Synthes©, Raynham, Massachusetts, United States of America) in six patients, Novabone© calcium phosposilicate (MTF©, Edison, NJ, United States of America) in one patient, and autologous bone obtained from a bone filter or a bone scraper in two patients. In another four patients, a bone block graft procedure [Figure 2] before the implant insertion was needed (three of these patients from the secondary alveoloplasty group and one in the late alveoloplasty group). In these patients, the donor site was the mandibular symphysis. The bone block was fixed by means of one or two 1.5-mm screws. In patients treated with a regrafting procedure, implants were inserted about 6 months after it [Figure 3].
Figure 2: Sequence showing a regraft by means of bone block and dental implant placement in a patient who was performed late alveoloplasty

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Figure 3: Final result of the patient indicated in Figure 2. Optimal esthetic and functional result can be appreciated

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Regarding the number of implants, 16 patients needed one dental implant (lateral incisor replacement), five patients needed two implants, and one patient needed three implants. Three patients each needed seven, six, and five dental implants, respectively.

No implants were lost in this period of follow-up, that as we mentioned above ranges from 6 to 153 months. The final evaluation of these patients was January 2016.


  Discussion Top


Treatment of the cleft lip and palate patient involves a long process that ranges from very early stages of growth to adolescence and adulthood. A multidisciplinary team that encompasses multiple specialists is necessary to achieve the desired result. Alveoloplasty represents an essential procedure to assure a bone foundation that permits an adequate orthodontic treatment and a final dental rehabilitation.

Between 10% and 50% of patients undergoing alveoloplasty do not achieve an adequate orthodontic treatment closure of the dental spaces.[14] The decision for closing the dental spaces is determined based in multiple variables including the occlusal anteroposterior, vertical, and transversal relationships, the quality of the alveolar ridge, the size and shape of the contralateral lateral incisor and canine, the relation between the dental midlines, the smiling incisors exposure, the periodontal health of adjacent teeth, and the presence of an oronasal fistula. The options are orthodontic guidance canine, a tooth autotransplant, or keeping the dental space and closing it with a removable prosthesis, a standard prosthetic bridge or an implant-supported crown.

Closure the dental space by means of a dental implant is a relatively recent modality of treatment. In fact, it was first published by Verdi et al.[5] Since then, some publications have been published;[5],[6],[7],[8],[9],[10],[11],[12],[13],[16],[17],[18] however, the number of patients included is limited. To the best of our knowledge, there are currently three reviews of dental implants in cleft lip and palate patients,[14],[19],[20] and the largest published series corresponds to de Barros Ferreira et al.,[16] with 120 patients and 123 dental implants.

In spite of the properties of implant treatment, not always is possible, as the rehabilitation with implants requires an adequate periodontal and alveolar status. One of the success criteria of alveoloplasty is the volume of bone that remains in the cleft alveolar region. The most commonly used assessment is the Bergland[2],[4] scale, which indicates the percentage of bone height in relation to the root length of the proximal and distal tooth to the alveolar defect. The importance of bone height lies not only in the adequate periodontal support for the teeth and the orthodontic process but also for the subsequent implant rehabilitation. If there is not an adequate volume of bone it is not possible to insert the implant; otherwise, it needs a re-grafting procedure, a common situation due to the lapse of time between alveoloplasty and implant insertion, 102 months in our series. Apart from the lapse of time between the bone graft and placement of the implant, the bone height at the time of implant insertion depends on the initial success of the alveoloplasty, the subsequent orthodontic treatment, and is negatively influenced by and advanced patient's age, a poor periodontal status (it is very important to use keratinized gingival flaps in the alveoloplasty procedure), tobacco habit, an incomplete wound closure and a not adequate maxillary immobilization in bilateral cases.

Although there is no current consensus on the optimal time for performing the procedure,[20] the usual timing for implant dental rehabilitation includes the placement of the implant when all the teeth were erupted, and the orthodontic treatment is in the final stage, generally after 16 in females and 18 in males. In the literature review, only one patient has received an implant before completing the growth (10-year-old).[20] We included a 14-year-old patient after finishing the orthodontic treatment.

The problem in delaying the insertion of implants is the high percentage of resorption encountered at the time of the procedure, more than a half in our series (13 of 23 patients), which has been achieved by GBR (nine patients) in mild bone resorption or with block bone grafts (four patients) in moderate resorption. These data are lower than those currently published.[14],[20] Although a study published in 2015 by Papi et al.[15] comparing the conventional treatment with removable partial or fixed prosthesis versus implants-supported prosthesis in patients with cleft lip and palate, shows a better satisfaction in the implant group, there are not published reports showing safe results in a long-term basis. Wang et al.[14] have reported a systematic review of this aspect showing a difference in marginal bone loss around implants ranging from a mean of 0.28 mm at 40-month follow-up and a mean of 3.5 mm at 76-month follow-up. Therefore, it is necessary to perform more studies in a long-term follow-up basis evaluating the development of peri-implantitis and other implant complications.

In our series, the survival of implants was 100%, similar to others reports in the literature.[8],[13],[14],[20],[21]

Although some authors point out the length of the implant as an important factor for its survival,[14] we do not consider this factor as relevant for survival (almost all implant for lateral incisor replacement are 10 or 12 mm long and 3.3 mm wide).

An aspect that should be addressed for the treatment optimization is the frequent impairment of soft-tissue esthetics in the cleft area, and hence the importance of putting keratinized mucosa in the occlusal rim while performing the alveoloplasty. Some authors describe a modification of the classical flap of the secondary cleft alveoloplasty, with minimal injury of dental papillae, with good wound healing.[22] Previous scars, the absence of keratinized mucosa, an unpredictable soft-tissues behavior, and the absence of interdental papilla may cause discomfort for oral hygiene, also social constraints when the individual smiles and exhibits the deficient gingival tissue, and results in high rate complication in this surgery.[17] Therefore, concomitant to the diagnosis and indication of dentures, periodontal principles should guide the planning of the prosthetic work, as it is essential to maintain adequate periodontal health conditions. Surgical therapies performed more frequently are gingivoplasty, gingivectomy, free or pedicle gingival graft, vestibule deepening with or without free gingival graft, removal of frenula, and restoration of biological dimensions.


  Conclusions Top


The dental rehabilitation of individuals with cleft lip and palate is one of the last treatment stages, after growth completion and finalization of orthodontic treatment. When alveoloplasty succeeds, implant insertion can have the same survival rate as in standard alveolar bones. Dental rehabilitation with implants is a safe procedure to close the edentulous gap in cleft patients and is the election technique in almost all cases, although more difficult. Many patients need regrafting and soft-tissue surgery previously to the implant placement. Long-term follow-up is necessary in these patients, and more studies are needed to establish specific clinical protocols.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]


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