Tuesday, January 30, 2018

The Role of Endosseous Implants in the Management of Alveolar Clefts

Resident’s Name:            Carol Caudill                                                                       Date: 1/31/2018
Article Title: The Role of Endosseous Implants in the Management of Alveolar Clefts
Author(s): William A. Pena, Karin Vargervik, Arun Sharma, Snehlata Oberoi
Journal: Pediatric Dentistry
Date: 2009
Major Topic: Implants and alveolar clefts
Type of Article: Literature review
Main Purpose: To review dental literature focusing on implants used in association with repaired alveolar clefts
Key Points: The best time for initial secondary alveolar bone grafting in between 8 and 11 years old. Implants should be placed within 6 months of bone augmentation. Implants that are at least 13mm long have a higher survival rate.

Infant oral orthopedic treatment
·      There is controversy as to whether nasoalveolar molding and gingivoperioplasty provide long-term benefits. Current studies are divided and future research is needed.

Orthodontic management
·      Patients with an alveolar cleft usually undergo Phase I ortho including maxillary expansion. This is followed by bone grafting between the ages of 8 and 11 before canine eruption. The lateral incisor on the cleft side is usually missing so a decision has to be made as to whether to do canine substitution or implant placement

Hypodontia and prosthetic rehabilitation in patients with alveolar clefts
·      Tooth agenesis in the area of the cleft is common
·      There is a high survival rate for implants placed in grafted alveolar clefts, so implants should be considered as an option

Alveolar bone grafting
·      Autogenous marrow bone harvested from the iliac crest is considered the gold standard when doing alveolar bone grafting for filling an alveolar cleft.
·      Primary bone grafting: usually done before the age of 2. Not recommended because it can mess up the growth of the maxilla
·      Secondary bone grafting: done in the mixed dentition when the unerupted canine has a root length between 1/2 and 3/4. This is recommended.

Endosseous implant placement
·      After the alveolar graft at 8-11 years old, the space is held until the patient is 15-17. Then the area is regrafted using an autogenous graft. The implant is then placed 4-6 months later. This time interval is important. If the implant is placed before this time period, it can fail due to lack of stability. However, if you wait too long after the graft you lose alveolar bone width and height.
·      Studies have shown between a 90-99% success rate with this protocol.

Implant properties and long-term outcomes
·      The dimensions, surface coatings, and implant location all contribute to the long-term success or failure of an implant
·      Bone density plays a major role in implant success vs failure

Implant length
·      Implants of less than 10mm can result in early failure
·      One study found that implants of 13mm or longer had a 93% success rate vs shorter implants that had a 62% success rate

Implant diameter
·      So far, studies have not found that implant diameter plays a role in implant survival in grafted alveolar cleft sites.

Surface coating
·      Studies are inconclusive as to whether implant surface coating play a role in long term longevity of the implant.
Assessment of Article:  Level of Evidence/Comments: Level III background information

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