Ministry of Education & Training Ministry of National Defense
108 Institute of Clinical Medical & Pharmaceutical Sciences

VO VAN NHAN
DENTAL IMPLANT PLACEMENT ON ALVEOLAR
BONE GRAFTED PATIENTS AFTER CLEFT LIP AND
PALATE RESCONTRUCTIVE SURGERY
Specialty: Odonto - Stomatology
Code: 62.72.06.01
PH.D THESIS SUMMARY
Hanoi - 2014
THE RESEARCH WAS FINISHED AT
108 INSTITUTE OF CLINICAL MEDICAL &
PHARMACEUTICAL SCIENCES
Full name of scientific instructors:
1. Assoc.Prof. Ph.D. Le Van Son
2. Ph.D. TaAnh Tuan
Judge 1:Assoc.Prof. Ph.D. Trinh DinhHai
Judge 2: Ph.D. Le Hung
Judge 3: Prof. Ph.D. Le GiaVinh
The thesis will be defended before the Thesis Assessment
Council at Institute level
At , date month year
Be able to search the thesis at:
1. National library
2. 108 Institute of Clinical Medical & Pharmaceutical
Sciences Library
3
I. RATIONALE OF THE SUBJECT
Cleft lip and palate (CLP) is the most frequently reported
congenital birth defect in the cranio-maxilo-facial field.

confidently for community integration.
IV. THESIS STRUCTURE
The thesis consists of 121 pages, not including appendices and
references. The contents of the thesis are: Introduction (2 pages),
Literature review (31 pages), Research subjects and method (29
pages), Research results (20 pages), Discussion (36 pages),
Conclusion (2 pages), Recommendations (1 page). The thesis has
23 tables, 4 diagrams, 12 charts, 69 pictures, 144 references (9
Vietnamese, English 135).
Chapter 1: LITERATURE REVIEW
1.1.CLEFT LIP AND PALATE
Cleft lip and palate are birth defects causing deficiency and
deformities of the nose, lips, palate that affects the formation of
unerupted tooth, teeth eruption, malocclusion, mastication,
distortion of the mesial floor and inferior floor of the facial,
pronunciation, the aesthetic and psychological diseases [94], [65].
Therefore, those who suffer from this malformation always feel
inferior andcan feel distance from community.
The treatment of CLP defects is a long process from the child
still in the womb to anadult with the cooperation of many experts
and various techniques including psychological counselling,
primary lip and palate repair surgery, alveolar cleft bone graft
surgery, orthodontic treatment, dental restorations, [101], [106].
1.2.ALVEOLAR CLEFT BONE GRAFT
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1.2.1. The necessity of alveolar cleft bone graft
Alveolar cleft bone graftingprovides room for orthodontic
movement of the teeth in the position of #3 and #2 (canine and
lateral incisor) to erupt into the cleft or for dental prosthesis,
maintain bony support of teeth adjacent to the cleft, preserve the

cleft such as iliac crest cancellous bone graft [46], iliac crest bone
block graft [31], autogenous bone graftwithartificial membrane
barriers covering graft material [100], the use of a cortex bone
plate (CBP) along the lining of thepalatal suture line[85] and
lateral corticalbone plates from the symphysis[127]. But so far,
these techniqueshave not been commonly used in alveolar cleft
bone grafting.
1.2.5. Evaluation methods of bone graft result
1.2.5.1. Means of evaluation
Some authors evaluate the results of bone graft by histology
[60] but the most popular is still by computed tomography,
including periapicalradiography, occlusalradiography, panoramic
radiography, conventional CT and Cone Beam CT.
The results of alveolar cleft bone graft was previously
mainlyassessed by periapicalradiography and
occlusalradiography[46], [54], [55], [72], [81] but these films did
not measure the buccal-lingual distance of the graft [77].
Therefore, Cone Beam CT today has become popular and useful
in assessing changes in volume and size in 3-dimension[59],
[137].
1.2.5.2. Evaluation scale
Nowadays, for the assessment of the alveolar bone graft outcome,
most of thestudies usethe combination of two-dimensional film
7
Figure 1.16:Enermark scale[42]
(periapicalradiography and occlusalradiography) through the
evaluation scale of the bone bridge formation in the cleftand
CTCone Beam to examine the 3-dimensional size or volume of
the graft [24], [26], [61], [79], [128], [137]. Several scales are
applied such asEnermarkscale (1987) [42], Berglandscale (1986)

1.2.1. Research design:
This thesis useda prospective uncontrolled clinical trial method
to evaluate alveolar cleft bone graft outcomes and implant
success.
Sample size: 32 patients by the averageestimating formula.
1.2.2. Research time:August, 2010 to February, 2014.
1.2.3. Research procedure:
Firstly, patient information was collectedwith a case history
form. After orthodontic and general dental treatment, alveolar
cleft bone grafting surgery was conducted with the technique of 2
iliac corticocancellousbone block autograft. 4 to 6 months later,
the implant placement was performed; 6 months later, prostheses
on the implant was executed.There was continued follow-up 15
and 18 months after the alveolar cleft bone grafting.
1.3.Surgical procedure
1.3.1. Iliac bone block harvesting surgery
A5cm incision over the superior iliac crestwas made 1 cm from
anterior superior iliac spine to prevent damage of the lateral
femoral cutaneous nerves. Thesubcuticular structure and
mucoperiosteumwas infiltrated and then dissection of the
periosteumwas carried out to expose iliac bone. Ultrasonic
piezotome device was used to make 4 cuts: the first cut of 4cm on
the superior iliac crest away from the cortical bone in the
9
abdominal cavity of 0.5cm, the second and the third cuts with the
length of 2cm were perpendicular to the first cut. The fourth cut
was perpendicular to the second and the third cuts. These four cuts
created a rectangle. A chisel was used to harvest the bone block
including the cortical and cancellous bone with the size of 4 x 2 x
0.5cm

Figure 2.31: The cleftwas nearly filled by cancellous bone
Figure 2.29:
Nasal flap closure
Figure 2.30: The bone block on the nasal lining
Figure 2.28: The incision for flap design on the vestibular
Step 1: Placement of cortical bone plate on the labial (nasal)
aspects of the alveolar process defect: The iliac bone block was
cut into 2 blocks. The first corticocancellous block with the size of
the cleft size was placed on the sutured nasal mucoperiosteum
(Figure 2.30). The cancellous bone was added on the plate until it
nearly filled the cleft (Figure 2.31)
Step 2: The second corticocancellous block with a larger size
than the cleft was placed on the grafted cancellous bone covering
the whole cleft and secured by screws for a tight fixation(Figure
2.32).
Step 3: The wound closure: the palatal
mucoperiosteumandthe vestibular mucoperiosteum wereclosedby
the suture on the alveolar crest. Vestibular mucoperiosteum
wassutured onboth sides of the cleftfrom the ridge of the alveolar
crest towards thevestibular recess. The suture was continuedto
recover the sulcus gingiva of the tooth from the cleft area. Finally,
mucosa closure was made with the vertical tension-freeincision
from the vestibular recess towards thealveolar crest (Figure 2.33).
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1.3.3. Implant placement surgery and implant
prosthodontics
+ Implant placement in the aesthetic zone [29]: Using implant
surgical guide to ensure: Implant direction passes the occlusal
edge of the further prostheses;In the buccal-lingual dimension, the
buccal side of the implant is 2mm from the buccal side of the

Type I and Type II are considered successful. Type III is
partial failure. Type IV is completely failure.
- Assessment of bone grafting result by CT Cone Beam
• The apical-coronal distance: marked as d, is measured from the
lowest point and the highest point of the grafted bone on CT slices
through the adiaphanouslocation axis on the surgical guide.
• The buccal-lingual distance: marked as r, is the average of the
apical-coronal distance of 1/3 superior (a), of 1/3 mesial (b) and
of 1/3 inferior (c), r = (a+b+c)/3.
• FollowingRenouard’s standard (1999): if the apical-coronal
distance is at least 7mm and the buccal-lingual distance is at least
4mm then there isenable for implant placement [47]
1.4.4. Assessment of implant placement
- Assessment of the success of implant oseointegration by
Misch’s criteria (2008) [89] included 4 levels:
o Success: if no pain in function, no clinical mobility is noted, less
than 2.0 mm of radiographicallycrestal bone loss is observed
compared with the implant insertion surgery, no history of
exudate.
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o Satisfactory survival: if they are stable, no observable pain and
mobility in function, radiographic crestal bone loss is between 2.0
and 4.0 mm from the implant insertion.
o Compromised survival: with no pain in function, no mobility,
greater than 4mm radiographic crestal bone loss but less than 50%
from around the implant, more than 7mm of probing depths, often
accompanied with bleeding.
o Failure: if any of these conditions are presented: pain in function,
mobility, more than ½ implant length of bone loss, uncontrolled
exudate, or has been surgically removed.

3.2. Result of alveolar bone graft
3.2.1.Mucosa condition of the recipient
At the follow-up 7 days postoperatively, 29 cases (90.6%)
reported good healing. A wound dehiscence occurred in three
patients (9.4%) resulting in a partial loss of bone, but the region
healed uneventfully after exfoliation of small bone fragments.
After 4 to 6 months, 100% of cases showed good healing.
3.2.2.Result of alveolar bone graft
3.2.2.1.Result of bone formation usingEnermark scale
In the follow-up 4 to 6 months after the bone graft surgery, the
bone formation type I was 90.6% and type III was 9.4%. There
was no change after 12 and 15 months.
After 18 months postoperatively, 1 patient appeared bone
resorptionwhich dropped from type I to type II. However, type
Iand type II are considered as successful by Enermark, so the total
success rate of the graft was 90.6% (Table 3.30). Bone bridge
formation in the cleft at the point of 18 months compared with the
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point of 6, 12 and 15 months showed no statistically significant
differences (p<0,05). Thus, implant placement can limit bone
resorption.
Table 3.30: Result of bone formation at 6, 12, 15 and 18
monthsafter alveolar bone graft (n=32)
Point of
times
Bone bridge level Total
I II III IV
4 - 6
months
29

9,4%%
0%%
3.3. Result of implant placement
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- Total of 32 implants were placed, of which 31 implants were of
size 3.8 x 10mm and 1 implant was 3.8 x 12mm. Of 32 patients, 3
patients had 2 implants placed, 26 patients had 1 implant placed.
- Initial implant stability: over 35N/cm
2
in 12.4% of implants,20-35
N/cm
2
in 43.8%and 15-20N/cm
2
in43.8%.
- Additional bone graft during implant placement were performed
in all 32 patients, in which 90.6% usedcancellous particulate bone
graft and 9.4% used ring bone and cancellous particulate bone
graft.
3.3.1. Result of implant osseointegration
Table 3.31: Result of implant osseointegration at 12, 15 and 18
months after alveolar bone (n=32)
Point of times Results on implant osseointegration
Total
number
of
implant
Post
bone
graft

12
months
31
(96.9%)
1 (3.1%) 0 0 32
(100%)
p=0.999
After 12 months follow-up,100% implants were successful and
therewas no change after 15 months follow-up. However, after 18
months, 96.9% (31 implants) were successful, 3.1%(1 implant)
appearingwith 2mm bone loss making it become satisfactory
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survival, no implant failure. The total survival of implants in good
function were still 100%. The survival rate at the point of 12 and
15 months had no significant difference compared to the point of
18 months (p<0.05).
3.3.2. Esthetic result of the prostheses on implant
+ Esthetic result followed pink esthetic score (PES) and
white esthetic score (WES) based on Belser’s standard (2009)
[23]:
Table 3.32: Esthetic resultof prostheses on implant at9 and 12
monthsafter implant placement(n=32)
Point of times
Esthetic result of prostheses
on implant
Total
Post
bone
graft
surgery

(28.1%)
32
(100%)
In the follow up of 9 and 12 months after implant placement,
18 implant prostheses (56.3%) were esthetical success, 5
prostheses (15.6%) were clinical acceptableand 9prostheses
(28.1%) were estheticalfailure (Table 3.32).
- Result of degree of patient satisfaction of the prostheses on
implant:
In the follow up of 9 and 12 months after implant placement,
21 patients (72.4%) were above satisfied with their prostheses, 8
18
patients (27.6%) satisfied and no patients disappointedwith their
prostheses on implants (Table 3.33)
Table 3.33: Result of the degree of patient satisfactionof the
prostheses on implantafter9 and 12 months after implant
placement (n=29).
Point of time
Patient satisfaction of the
prostheses on implant
Total
Post
bone
graft
surgery
Post
implant
surgery
Above
satisfied

KhacTham’sstudy was 21.7% [9]. Thus, patients with Angle Class
III in our study wassignificantlyhigher than patients without
defects (p <0.05). This rate was suitable with Posnick’sstudy
(2000) [105].
All patients were treated orthodontic for aligning and making
suitable horizontal spaces forfuture prostheses, facilitating
flapdesign, flapdissection and flap closure. It also helpsplacing,
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fixing the graft, determining the volume of bone graft easily as
well as the prognosis of the location and orientation of the implant
that fit the future prostheses. Furthermore, orthodontic treatment
was continued after bone graft surgery that is recommended bya
lot of authors as the traction on bone graft will help stimulate the
graft’s development (Turvey 1984 [136]).
Each patient had 9.8 decays on average and the DMFT Index
(Decayed, Missing and Filled Teeth)was 10.5 with no
significantly difference (p=0.388> 0.05), whichmeans the subject
had not had oral treatment before. 12 patients
(37.5%)presentedwith residual tooth in the cleft area. Jia (2006)
[64] said that poor oral hygiene often leads to infection,
complications and dehiscence after bone graft surgery. To prevent
the above complications, all patients received dental treatments,
gum treatment and oral hygiene instructions in the treatment
process. Residual teeth in 12 cases were extracted at least 2
months before the bone graft surgery to ensure there wasmature
gum tissue in the extraction area making better condition for flap
closure.
4.2. Timing and purpose of the alveolar bone graft
In our study, all patients receivedintermediate secondary bone
grafting in the age of over 16 years with the purpose of implant

On the periapical radiography using Enermark scale, the
bone formation after 6, 12, 15 months after bone graft surgery
showed that 90.6% of the graft were successful (type I and II),
9.4% were partial failures and no cases were completely failed.
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After the follow-up of 18 months, 1 case of type I bone
formation (3.1%) turned into type II because of bone resorption
around the implant, 3 cases of type III (9.4%) turned into type IV.
Type II was still considered successful, so the final success was
still 90.6% after 18 months follow-up.
Our bone graft result was similar to Abyholm’s study(1981)
with a success rate of 91% [10] or Bergland’s study (1986) of
90% [24]. Besides, this result was higher than Collin’s with a
success rate of86,86% [32],Amanatand Langdon’s (1991) of 83%
[17], Grant’s (2009) of 76% [54], Nightingale’s (2003) of 71%
[93], Witherow’s (2002) of 65% [143]. These studies were
carried out in the subject with mixed dentition which had
favorable conditions than the permanent dentition [36], [37]as
Abyholm (1981) [10], Waite (1987) [140] andPaulin (1988)
[99]reported that proliferative activity of bone marrow is stronger
and obtain larger bone volume in younger patients (mixed
denture) than older patients (permanent denture). The older the
patients are, the greater bone resorption occurs and the wider the
clefts are.Besides, Dempf’s study [36] in patients with permanent
teeth with an average age of 21.3 that was similar to our subjects
which showed the success rate was 68%, which was lower than
our results. That may be explained as we used the following
methods: improvement in bone graft technique usingtwo iliac
corticocancellous block technique (to limit bone resorption and
reach rapid healing); technical combination by sliding flap,

several following reasons: the improvement in bone graft
techniqueof two iliac corticocancellous block technique (with the
rigid mechanical properties of cortical bone that limit bone
resorption and easily obtain the implant initial stability) compared
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to the use ofonly iliaccancellous bone in other studies [57], [68],
[74]. According toAlbrektson (1980) [11],iliaccancellous bone
presents fasterhealing, but more bone loss after the healing
process; At the same time, we applied the technique increasing the
implantsinitial stability such assmalldrill holes, large diameter of
implant, bone compression, tapered implant, the processed
implant surface and more thread in the implants neck area which
helps increase the contact area between bone and implant surface;
Implant placement were performed 4 to 6 months after bone graft
that the mature graft were obtained and bone resorptionhad not
yet happened too much compared to studies with
increasedduration from bone graft to implant placement [131];
Implant with standard length of 10mm was used to ensure the
biomechanics stability for lateral incisor [130]; Besides, in the
additional bone grafting during implant placement, we used
autologous bone from the mandibular symphysis or the retromolar
combined with synthetic materials for better bone integration
whileCuneproposed using only synthetic materials (2004) [34].
Partially, itmay be the follow-up period in our studies were shorter
than other studies that failure has not occurred yet.
4.5.2.Esthetic result of prostheses on implant
According to the aesthetic standards by Belser, the results of
our study showed that 18 implant prostheses (56.3%) were
esthetically successful(score >12), 5 prostheses were clinical
acceptable(score =12) and9 prostheses were

palate defect.
Although the aesthetic results followingBelser’s standard was
not high, 100% of patients weresatisfied with their dental
25
restorations, including the aestheticalfailuresof 28.1% assessedby
clinicians. In cleft lip palate patients, the initial conditionswere
too complex andunfavourablewith the presence of cleft lip defect
(no bones, no gums, no teeth), the presence of fistula, malposition
of teeth around the cleft, malocclusion, arch deformity, After
treatment, no fistula, no cleft, bone, gums and teeth were
obtained. This result brings big changes for patients themselves,
so the teeth in the cleft areasbeing longer than the contralateral
tooth was not so important to them, moreover,the longer sections
of the tooth was invisible when smiling or talking because
thesesubject had a low smile lines [43] which meant it did not
affect the patient’saesthetics and communication. Therefore, all
patients were satisfied with their implant prostheses.
CONCLUSION
1. Jaw bone condition after alveolar bone graft
The mucosa on the alveolar ridge after bone graft surgery
presented good healing, all oronasal fistulaswere closed and pink
and healthy mucosa lining wascontinuous with the maxillary
mucosa.
After alveolar bone graft with the technique of two
corticocancellous blocks, jaw bone volume was reconstructed:
• In the apical-coronal distance: 11.4 ± 2.4 mm
• In the buccal-lingual distance: 6.1 ± 1.0 mm
90.6% of cases obtained the bone height in the cleft
approximately to normal and 90.6% of cases wereviable for
implant placement.