Vuletić, M., Knežević, P., Jokić, D., Rebić, J., Žabarović, D., & Macan, D. (2014). Alveolar Bone Grafting in Cleft Patients from Bone Defect to Dental Implants. Acta stomatologica Croatica, 48(4), 250–257.
Cleft lip and palate is the most prevalent congenital craniofacial deformity, which significantly impacts various aspects of life, including aesthetics, function, psychological well-being, dental development, and facial growth. It’s evident that the known primary cause is the incomplete fusion of facial prominences during gestation’s fourth to tenth week which can be corrected with surgical intervention, known as an osteoplasty. This fundamentally includes closing cleft gaps through alveolar bone grafts using autogenic bone harvested from the iliac crest which appears to be the gold standard. Whilst this procedure addresses the alveolar defect associated with the development of the maxillary canine root, it’s only typically conducted between ages 7 and 11.
Whilst successful osteoplasty closes the cleft defect, the challenge of (congenitally) absent teeth remains, as seen in Fig 1. Despite adopting Orthodontic treatment for space closure, alternative options for tooth replacement are explored including: adhesive bridgework, tooth transplantation, and dental implants. Fundamentally, dental implants play a crucial role in supporting dental prostheses, preventing significant bone atrophy, and loading augmentation material in the cleft area.
Fig 1. Panoramic radiograph before secondary alveolar cleft bone grafting of 11-year old patient with unilateral cleft lip and palate
Even though the effectiveness of autologous bone from the iliac crest is considered the gold standard, there are certain limitations. On the other hand, bone morphogenic protein (BMP) presents itself as a promising alternative graft material, offering potential benefits such as eliminating donor site morbidity, reducing operation time and costs, and a shorter hospital stay.
The prevalence of cleft lip and palate varies among populations, with the highest incidence in specific ethnic groups. Understanding the multifactorial aetiology, including genetic and environmental factors is crucial for effective management. Furthermore, it’s evident that surgical interventions, such as primary and secondary alveolar bone grafting have evolved over time. Early attempts in the early 20th century paved the way for improvements in surgical techniques, with the introduction of secondary bone grafting in 1972 providing significant advancements.
Fig 2. Incision and flap elevation for secondary alveolar bone graft
Moreover, surgical procedures involve meticulous steps, such as harvesting autogenic spongy bone from the iliac crest and creating full-thickness mucoperiosteal flaps to cover cleft fissures, shown in Fig 2. The timing of grafting, whether primary or secondary, is carefully considered based on the patient’s age and dentition stage.
Subsequently, post-surgical success is often measured by the stabilisation of maxillary segments, support for tooth eruption, and overall improvement in facial morphology and growth. Dental anomalies are common in cleft patients, thus necessitating additional interventions like orthodontic treatment or, in severe cases, dental implants.
Implant and prosthodontic rehabilitation and future techniques
In comparison to orthodontics, implant and prosthodontic rehabilitation become imperative for patients with a lack of teeth post-osteoplasty (Fig 3); adhesive bridgework, tooth transplantation, and dental implants offer viable solutions as seen in Fig 4. Additionally, modern adhesive techniques and reduced caries rates contribute to the increasing popularity of adhesive bridgework. The use of dental implants, although requiring careful consideration of bone volume, presents a reliable option for patients, offering an oral-health-related quality of life similar to non-cleft individuals.
Fig 3. CT scan of patient with bilateral cleft lip and palate before osteoplasty
Fig 4. Final prosthodontic and rehabilitation with implants and crowns
In conclusion, this comprehensive review delves into the intricate aspects of cleft lip and palate, covering historical developments, surgical techniques, and the evolving landscape of implant and prosthodontic rehabilitation. The integration of innovative approaches, such as BMP and dental implants showcases the ongoing efforts to enhance outcomes and quality of life for individuals affected by this congenital deformity.
Research Summary Written By: Hafsah Rizwan Waraich, University of Manchester – BDS2