Case Report - Developmental Defect

Esthetic and functional rehabilitation in patients with

cleft lip and palate
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Vasilios A. Bousdras, Peter R. Ayliffe1, Mark Barrett2, Colin Hopper3
www.amsjournal.com Private Practice, Al. Mihailidi 9, Thessaloniki 54640, Greece, 1Maxillofacial Surgeon, Maxillofacial Unit,
DOI: Great Ormond Street Hospital, 3University College Hospital,
10.4103/2231-0746.161109 2
Prosthodontist, University College London Hospitals, London, UK
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Address for correspondence:

Mr. Vasilios A. Bousdras, Maxillofacial Surgeon, Private Practice, Al. Mihailidi 9,
Thessaloniki 54640, Greece.
E-mail: [email protected]

ABSTRACT

Oral rehabilitation of missing teeth in cleft patients has acceptable success rates. A two-stage approach is indicated; however,
timing of implant placement in the grafted maxilla varies within existing protocols. This case highlights successful implant
osseointegration and esthetic oral rehabilitation following placement of two implants at 5 months after maxillary grafting
(alveolar bone grafting) with a corticocancellous block obtained from the iliac crest. A 31-year-old male patient had already
undergone repair of his bilateral cleft lip and soft palate according to established guidelines for cleft patients. Initial closure
of his alveolar clefts and further correction of the maxillary hypoplasia with a bi-maxillary osteotomy were completed in 2002.
However, bone resorption due to infection in 2003 necessitated removal of all maxillary incisors. The patient was not satisfied with
the removable partial denture provided. In 2007, he did undergo anterior maxillary augmentation under general anesthesia, and
5 months later two implants were placed. A 3-unit bridge did replace functional and esthetic demands. Postoperative recovery
was uneventful, and overall bone loss, and oral health remain within standards 28 months following implant placement. Optimal
outcome is achievable when replacing missing teeth in cleft patients when timing does not exceed approximately a 6-month
interval from bone grafting to implant placement. This article demonstrates that overall esthetic and functional rehabilitation
is feasible in cleft lip and palate patients. In this patient, overall oral treatment was achieved with an implant prosthesis.

Keywords: Cleft palate, functional rehabilitation, graft, reconstruction, tongue flap

INTRODUCTION (1) Very early secondary bone grafting, which facilitates the
eruption of the lateral incisor but probably inhibits maximal
Cleft lip and palate (CLP) represents the second most frequently growth of the maxilla, (2) early secondary bone grafting depending
occurring congenital deformity. It is associated with problems upon the development of the upper canine, which facilitates the
including cosmetic deformities, oral abnormalities, speech, eruption of the canine into the graft and permits the maxilla to
swallowing and growth difficulties. Due to their congenital develop undisturbed for a longer period and (3) late secondary
deformity, alveolar bone grafting (ABG) is an essential step in their bone grafting after eruption of the upper canine.
reconstruction.[1] Oral rehabilitation includes the replacement of
missing teeth, and the use of endoosseous implants has become Grafting of the cleft is accomplished with cancellous bone from
a secure option of treatment with predictable and acceptable the ilium or tibia or corticocancellous from the calvarium or
rates.[2-4] Time of grafting has been controversial among surgeons. mandibular symphysis.[1,6-9] Also, the use of chest rib as a donor
There remain a few supporters of primary bone grafting,[5] in site has been reported, and there is a growing interest in the use
which the cleft alveolus is usually reconstructed at the same time of bony substitutes to reconstruct maxillofacial defects.[10] The
as the closure of the cleft lip, or shortly thereafter. Secondary question of the preferred donor site for alveolar cleft grafts has
bone grafts are more popular and can be placed at three stages: been debated for many years. Its choice is influenced by several

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 Bousdras, et al.: Cleft lip and palate treatment

factors that include the surgeon’s experience and preference, the resorption due to severe oral infection in 2003 necessitated
volume of bone that is required and available, and the morbidity removal of all maxillary incisors [Figure 1a and b]. The patient
that is associated with its harvest. was not satisfied with the removable partial denture provided.
In 2007, he did undergo anterior maxilla augmentation with two
Many reports suggest that autogenous bone from the iliac crest corticocancellous blocks obtained from the anterior iliac crest
is the gold standard by which other types of alveolar grafts under general anesthesia, secured with 10 mm screws [Figure 2].
should be compared.[1] It is easy to access and can supply large Five months later two 10 mm 4.1Ø Straumann implants (Basel,
quantities of cancellous bone with pluripotent or osteogenic Switzerland) were placed, which were left another 7 months, prior
precursor cells that support osteogenesis in the early period second stage surgery and abutment connection. A 3‑unit bridge
after grafting.[3] Because of its higher content of osteogenic cells, did replace functional and esthetic demands [Figures 3 and 4].
cancellous bone is thought to be superior to corticocancellous Healing was uneventful and marginal bone loss and gingival
bone. The number of osteogenic cells/unit volume of cancellous health remains within standards 28 months following implant
bone can be increased further by compacting it, which is placement. Overall, the patient was satisfied with improved
thought to increase its reliability even further. [3] The main appearance and masticatory function.
criticism of its use as secondary bone grafting is that it produces
an unacceptably high degree of postoperative morbidity, such DISCUSSION
as persistent pain, prolonged recovery time, hemorrhage,
limping, visible scarring, bone contour deformities, lesions Patients with CLP are at increased risk for the development of oral
of the lateral femoral cutaneous nerve, pelvic fracture and diseases, which are associated with both anatomic defects and
peritonitis.[11,6-8] long‑term orthodontic treatment.[14] Anatomic defects, delays in
the formation and eruption of teeth, problems with orthodontic
However, several studies have shown that the severity of movement, and the presence of prostheses, all contribute to
postoperative pain after iliac crest bone harvesting is minimum reductions in bone levels in the areas adjacent to cleft regions.
when a less aggressive surgical approach is followed with Maxillary arch segment irregularities, orthodontic appliances,
a trephine to obtain cores of bone. Most patients indicated and persisting soft tissue folds before palatoplasty as well as
that the pain was not severe and was readily alleviated with the presence of scar tissue after cleft closure make oral hygiene
small quantities of analgesics.[11] Furthermore, in most of the control difficult. All of these factors enhance the progression of
earlier studies evaluated pain experience following a graft the disease.[14] Prosthetic replacement of missing anterior teeth in
harvest procedure from the iliac crest, undergoing another the maxillary arch of cleft patients has always been considered
surgery (arthrocentesis etc.). an important part of their rehabilitation.[15] Wegscheider et al.,[16]
described the following possibilities:
Now‑a‑day, this surgical approach has been developed to • Fixed prosthodontics (crowns, bridges, and Maryland bridges)
a minimum invasive surgical intervention when bone is • Removable prostheses (conventional cast partials,
to be harvested for augmenting bone volume in advanced overdentures, and full dentures), and
oral implantology procedures. This is because the shape of • Precision prostheses (appliances with bars, splints, and
corticocancellous blocks and the amount of cancellous bone telescope retainers).
are approximately predetermined in the overall treatment
planning, and less aggressive instrumentation (i.e., trephines, These authors reported a 50% failure rate with Maryland bridges
saws) induce less trauma. Moreover, overall postoperative and attributed this to the high frequency of mobile teeth in the
discomfort can be significantly reduced by administering maxillary cleft segments. Of 12 fixed bridges placed, seven failed
a bolus of long‑lasting anesthesia locally immediately as a result of periodontal disease, marginal defects, or dissolution
postoperatively. of cementurn, and all four of the bar constructions had to be
removed because of marginal defects developing as a result of
Several surgeons have reported that roughly 86% of their patients poor access for oral hygiene.
would be willing to have an ABG using bone from the hip, if
recommended, and many patients are satisfied with the residual Studies conducted by Verdi et al., [17] Lund and Wade, [18]
scar.[11] Other surgeons have reported that harvesting bone from introduced prosthetic rehabilitation with endosseous implants
the iliac crest did not delay mobility, and almost all patients were inserted in grafted clefts. The implants can be inserted either at the
able to walk within the first 24 h after operation and could walk time of osteoplasty[19] or in a second operation. In the one‑stage
normally within 2 weeks.[11] Comparison between graft donor procedure (bone grafting followed by dental implantation),
sites can be seen in Table 1. there is a risk of unpredictable loss of height of the grafted
bone.[17,20] It is then sometimes necessary to graft additional
CASE REPORT bone in a two‑stage procedure.[21] Kearns et al.,[21] inserted 20
dental implants in 14 cleft patients and reported on the necessity
A 31‑year‑old patient had already undergone repair of his bilateral of additional bone grafting in six cases with the time between
cleft lip and soft palate according to established guidelines for osteoplasty and implantation being an average of 26.4 months
cleft patients in the UK. Initial closure of his alveolar clefts and (4–46 months). Deppe et al.[19] reported on a total of 14 patients
further correction of the maxillary hypoplasia with a bimaxillary with 14 implants and a time interval between osteoplasty and
osteotomy were completed in 2002. The palatal fistula was implantation of 6 months to 7 years without giving information
closed with an anteriorly based tongue flap.[12,13] However, bone on the necessity of a second bone graft. According to their

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 Bousdras, et al.: Cleft lip and palate treatment

Table 1: Comparison between graft donor sites

Site Advantages Disadvantages/complications
Ilium Large quantities of cancellous bone Mild pain, scarring, transient gait disturbance, dysesthesia
Decreased operative time with two team approach
Calvarium Minimal postoperative pain and discomfort Complications caused by harvesting range from 0.25% to 5.5% and include hematomas,
Scar hidden in the hair line seromas up to 9.5%, osteomyelitis 0.2%, dural exposure 5-12%, subdural hemorrhage,
leaking of cerebral spinal fluid and serious neurological problems 0.09%
Tibia Short harvesting time Need to operate on both legs because of insufficient amount of bone, complications
Two team approach of tibial fracture range from 0% to 2.7%, delayed mobilization, no contact sports for
Minimal bleeding, scarring 3 months
Excellent quality of cancellous bone
Mandibular Same site of operation Small amount of bone, possibility of loss of unerrupted teeth, necrosis of pulp,
symphysis Minimal pain, discomfort revitalization of teeth, mental nerve injury
Shorter stay in hospital
Invisible scar
Rib Two team approach Problematic visible scar, pleuritic pain up to 7%, risk of pneumothorax 5-30%

a b
Figure 1: (a and b) Radiographic assessment at 2006 of the previously Figure 2: Postoperative orthopantomogram on the first follow-up
grafted alveolar clefts. Note the narrow width of the alveolar ridge, visit following maxillary bone augmentation with iliac crest bone
especially in the right anterior maxilla, which is not suitable to (blocks secured with two titanium screws each in the anterior maxilla).
accommodate dental implants Titanium plate and screws in the mandible/maxilla were used for fixation
during the bimaxillary osteotomy and screws in the left infraorbital area
were used for fixation of an alloplastic facial implant for further masking
of maxillary hypoplasia

a b
Figure 4: (a and b) Clinical assessment of the fixed prosthesis at 18-month
Figure 3: Orthopantomogram following attachment of the implant fixed follow-up visit
bridge. A third implant was not accommodated due to infection of the
grafted right maxilla
and implant success rate was 82.2% at the end of the
observation period.
experience with 4 dental implants in three cleft patients, Ronchi
et al.[2] preferred a time interval of 6–12 months.
No cases were available in the literature with application of the
implant prosthesis earlier than an interval of 6 months. Bone in
Kearns et al. [21] reported a success rate of 90% in the the anterior maxillary area had considerably resorbed following
two‑stage procedure. The average time between implantation secondary ABG 15 years ago. Consequently, an additional grafting
and follow‑up was 39.1 months (1–54 months). Härtel procedure was necessary in order to provide adequate bone
et al., [20] reported a success rate of 96% with an average volume for the placement of the implants in the anterior maxilla.
time of 28 months (4–36 months) between implantation and Due to early infection, following the grafting procedure, there was
follow‑up whereas no bone resorption recorded in those space available to accommodate only two implants, which were
cases where the time between bone grafting and implantation enough to support a fixed 3‑unit bridge to replace missing teeth.
was only 6–8 weeks. Kramer et al., [22] conducted a long‑term Implants were placed within 6 months following grafting of the
follow‑up study with an observation period extended to maxilla and osseintegration was uneventful. Following a standard
5.5 years in average (minimum 1.5, maximum 11.3 years) hygiene protocol, implants remain in good health.

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Maxillofac Surg 1990;48:554‑8. and functional rehabilitation in patients with cleft lip and palate. Ann Maxillofac
9. Bousdras V, Newman L, Ayliffe P. Successful TMJ ankylosis release with Surg 2015;5:108-11.
a costo‑chondral rib graft in a teenager with a long term history of a road Source of Support: Nil, Conflict of Interest: None declared.
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