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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 78-81

Rehabilitation using dental implants following closure of large alveolar cleft defect by HYDIS-TB appliance: One-year follow-up


1 Department of Orthodontics and Dentofacial Orthopedics, Maulana Azad Institute of Dental Sciences, New Delhi, India
2 Department of Orthodontics and Dentofacial Orthopedics, University College of Medical Science, Delhi, India

Date of Submission17-Jun-2021
Date of Acceptance12-Aug-2021
Date of Web Publication01-Jan-2022

Correspondence Address:
Dr. Tulika Tripathi
Department of Orthodontics and Dentofacial Orthopedics, Maulana Azad Institute of Dental Sciences, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_24_21

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  Abstract 


Restoration of missing oral tissues in patients with cleft lip and palate is the biggest challenge in their rehabilitation. In this report, we described the postdistraction rehabilitation and 1-year follow-up of the regenerated bone by implant-supported prosthesis and orthodontic tooth movement. A novel distraction appliance regenerated natural bone which is compatible for both implant placement and orthodontic tooth movement, thereby restoring adequate function and esthetics.

Keywords: Alveolar defect, implant in distracted bone, orthodontics in regenerated bone


How to cite this article:
Singh N, Bhutiani N, Tripathi T, Rai P. Rehabilitation using dental implants following closure of large alveolar cleft defect by HYDIS-TB appliance: One-year follow-up. J Cleft Lip Palate Craniofac Anomal 2022;9:78-81

How to cite this URL:
Singh N, Bhutiani N, Tripathi T, Rai P. Rehabilitation using dental implants following closure of large alveolar cleft defect by HYDIS-TB appliance: One-year follow-up. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Jan 25];9:78-81. Available from: https://www.jclpca.org/text.asp?2022/9/1/78/333640




  Introduction Top


The missing tissues in the region of the cleft pose a great challenge to the successful rehabilitation for patients with cleft lip and palate. The various options for the replacement of missing teeth include a removable partial denture, conventional fixed prostheses, or implant-supported prosthesis.[1] In cases with large cleft defect, fixed prosthesis can be given only after bone grafting which may fail if the defect is >11 mm.[2] Furthermore, the fixed prosthesis may be challenging due to compromised bone support of teeth adjacent to defect. In such cases, removable partial dentures were advocated but cause resorption of the underlying alveolar bone due to compression.[3]

Distraction osteogenesis has emerged as a promising technique for natural hard and soft-tissue regeneration in such cases. We have devised a tooth-borne distractor appliance (HYDIS-TB) to overcome the shortcomings of existing appliances such as docking of transport segment superiorly, inadvertent tipping of teeth, and incomplete closure of bony defect on the nasal side.[4] Thus, good quality and optimum quantity of bone to support implants for functional and esthetic rehabilitation could be regenerated. The current report showed the rehabilitation and 1-year follow-up of our previously published case[5] where distraction osteogenesis was done to regenerate the deficient bone to restore the patient's occlusion.


  Case report Top


A 25-year-old male with repaired bilateral cleft lip; unilateral maxillary right alveolar defect and left facial cleft defect had been undergoing treatment in our department [Figure 1]. The maxillary arch was expanded to relieve crowding which revealed a large alveolar cleft measuring 15 mm [Figure 2]. HYDIS-TB appliance was successfully used with trifocal distraction [Figure 3], resulting in obliteration of cleft defect. Two transport segments were created by giving the vertical osteotomy cuts distal to the second premolar on the right side and distal to the lateral incisor on the left side. The horizontal osteotomy was performed 5 mm cervical to root apices of the teeth contained in the transport segments. The new bone was regenerated between the maxillary right second premolar-first molar and left lateral incisor-canine regions. In the current rehabilitative phase, the following clinical problems were identified; 8 mm space present mesial and distal to the second premolar in the maxillary right quadrant, whereas 7.5 mm space was present mesial and distal to the canine in the maxillary left quadrant, anterior edge-to-edge bite, well-rounded regenerated alveolar ridge in the region of distraction, which had adequate width for implant placement [Figure 4].
Figure 1: Pretreatment photographs

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Figure 2: Predistraction photographs and orthopantomogram

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Figure 3: Intraoral photographs with HYDIS-TB appliance

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Figure 4: Postdistraction photographs and orthopantomogram

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The patient had Class III skeletal bases (ANB-2°) with retrognathic maxilla (SNA 75°), average growth pattern (FMA 25°), and unfavorably impacted 28, 38, and 48 [Figure 4].

Based on the above problems, the following treatment objectives were outlined:

  • Consolidation of the maxillary arch
  • Creation of adequate space for rehabilitation of the missing teeth
  • Camouflage of Class III skeletal pattern
  • Creation of a positive overjet
  • Extraction of impacted 28, 38, and 48
  • Improvement of facial esthetics and occlusion.


Treatment progress

The treatment after alveolar distraction was carried out in two phases:

Phase I: Orthodontic treatment

The postdistraction leveling and alignment were done using 0.022 MBT appliance [Figure 5]. The right maxillary premolars were distalized into the regenerated bone using NiTi closed coil springs. Interproximal reduction of the lower incisors was done to create overjet and camouflage the skeletal Class III bases [Figure 6]. 28, 38, and 48 were extracted. The appliance was debonded, and custom-made esthetic retainers were placed in both arches. The duration of orthodontic treatment was 10 months.
Figure 5: Phase I-orthodontic treatment

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Figure 6: Postdebonded photographs

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Clinical and radiographic evaluation:

  • 8 mm space available on the right and 7.5 mm on the left side which was adequate for implant placement (minimum required = 6–7 mm)
  • Well-rounded ridges with healthy soft-tissue coverage
  • Adequate vertical clearance of 7 mm for prosthetic rehabilitation.


The density of regenerated bone was found to be 590.34 HU using cone-beam computed tomography [Figure 7].
Figure 7: Cone-beam computed tomogram with simulated implant placement assessing bone density

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Phase II: Implant placement and prosthetic rehabilitation

Osstem implants (Seoul, Korea) of 3.3 mm diameter and 10 mm length were placed bilaterally in maxilla. Porcelain-fused metallic crowns were given as permanent prostheses for maxillary left and right canines [Figure 8].
Figure 8: Postimplant placement: Postimplant insertion (a and b), prosthetic placement (c and d) postimplant orthopantomogram (e)

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The patient was followed up every 3 months for the next 1 year, and the implant was found to be stable [Figure 9].
Figure 9: One-year follow-up photographs

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  Discussion Top


The restoration of bone is critical in large alveolar cleft defects where the chances of graft failure are extremely high.[6] The procedure of distraction followed by implant placement in the regenerated bone has emerged as a promising solution in such cases as implants offer the best method for the replacement of teeth in contemporary clinical practice.[7] However, immediate implant placement following alveolar distraction was not possible in this case due to the distribution of spaces, presence of edge-to-edge bite, and lack of intercuspation in the posterior region, for which the second phase of orthodontics was planned.

Both skeletal Class III pattern and Bolton's discrepancy indicated interproximal reduction of lower incisors followed by retraction to achieve positive overjet. Thus, forward vector expression was warranted during the distraction, thereby maintaining upper incisors proclination. This enhanced upper lip support and demonstrated the possibility of customized force vector modification with this appliance. Furthermore, the need for orthognathic surgical procedure was minimized which would have been less stable due to scarring, muscle pull, and tension in the soft tissues.[8] The procedure of distraction allows for simultaneous soft-tissue regeneration and remodeling, leading to greater stability of results. Moreover, the movement of premolars into distracted bone aided in arch consolidation and provided functional loading that facilitates long-term stability by structural preservation of bone.[5]

The implant on the left side was placed in the newly regenerated bone, which had density of 590 HU. This value is comparable to the normal value of bone density optimum for anterior maxilla in various studies.[9],[10] The adequacy of bone density for implant placement was further reflected in the good primary stability achieved during implant placement as tested by the insertion torque ratchet, which was found to be 45NcM. Further, the secondary stability assessed before the prosthesis by periotest was highly satisfactory. Hence, the distraction protocol followed in the current case using the HYDIS-TB resulted in the generation of high-quality bone which physiologically paralleled the natural bone and could successfully harbor an implant that was stable even after a year.


  Conclusion Top


HYDIS-TB is a minimally invasive, vector-controlled, versatile, cost-effective, and simple appliance for the resolution of deficient bone. The bone regenerated was healthy and suitable for implant placement with good stability of results 1-year posttreatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Reisberg DJ. Prosthetic habilitation of patients with clefts. Clin Plast Surg 2004;31:353-60.  Back to cited text no. 1
    
2.
Fukuda M, Kochi SR, Takahashi T, Nagai H, Takano HY, Matsui K, et al. Bone graft in alveolar cleft with autogenous particulate marrow and cancellous bone: Unsuccessful postoperative result cases. J Jpn Cleft Palate Assoc 1996;21:156-163.  Back to cited text no. 2
    
3.
de Barros Ferreira S Jr., Esper LA, Sbrana MC, Ribeiro IW, de Almeida AL. Survival of dental implants in the cleft area--a retrospective study. Cleft Palate Craniofac J 2010;47:586-90.  Back to cited text no. 3
    
4.
Hegab AF. Closure of the alveolar cleft by bone segment transport using an intraoral tooth-borne custom-made distraction device. J Oral Maxillofac Surg 2012;70:e337-48.  Back to cited text no. 4
    
5.
Neha, Tripathi T, Mohanty S, Rai P. A novel minimally invasive technique of using tooth-borne hyrax expansion screw for distraction osteogenesis of large alveolar cleft defects (HYDIS-TB). Cleft Palate Craniofac J 2018;55:895-902.  Back to cited text no. 5
    
6.
Liou EJ, Chen PK, Huang CS, Chen YR. Interdental distraction osteogenesis and rapid orthodontic tooth movement: A novel approach to approximate a wide alveolar cleft or bony defect. Plast Reconstr Surg 2000;105:1262-72.  Back to cited text no. 6
    
7.
Gbadebo OS, Lawal FB, Sulaiman AO, Ajayi DM. Dental implant as an option for tooth replacement: The awareness of patients at a tertiary hospital in a developing country. Contemp Clin Dent 2014;5:302-6.  Back to cited text no. 7
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8.
Figueroa AA, Polley JW, Friede H, Ko EW. Long-term skeletal stability after maxillary advancement with distraction osteogenesis using a rigid external distraction device in cleft maxillary deformities. Plast Reconstr Surg 2004;114:1382-94.  Back to cited text no. 8
    
9.
Shapurian T, Damoulis PD, Reiser GM, Griffin TJ, Rand WM. Quantitative evaluation of bone density using the Hounsfield index. Int J Oral Maxillofac Implants 2006;21:290-7.  Back to cited text no. 9
    
10.
Turkyilmaz I, Tozum TF, Tumer C, Ozbek EN. Assessment of correlation between computerized tomography values of the bone, and maximum torque and resonance frequency values at dental implant placement. J Oral Rehabil 2006;33:881-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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