tóm tắt luận án tiên sĩ bản tiếng anh nghiên cứu cấy ghép implant ở bệnh nhân đã cấy ghép xương hàm sau phẫu thuật tạo hình khe hở môi và vòm miệng toàn bộ

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.

According to WHO, the overall incidence of cleft lip and palate is
reported around 1/500 live births [138]. This incidence is different
depending on regions and races:it’s low in the black and high in
Japanese, Chinese and Indian-American. In Vietnam, this
incidence is about 1/709 to 1/1000 [2], [7].
Around the world, some clinicians successfully applied
implant treatment for cleft lip and palate patients like Verdi (1991)
[139], Kearns (1997) [68],…. In Vietnam, the research on cleft lip
and palate patients mainly assess epidemiology and cleft lip -
palate closing technique [1], [3], [4], [5], [7], a few studies were
takenabout alveolar bone graft such as study of Nguyen Manh Ha
(2009) [6], or implant placement in normal patients without
defects of Ta Anh Tuan (2007) [8]. Thus, the implant placement
on the grafted bone and implant prosthetic on CLP patient is the
problem that has not been studied comprehensively in Vietnam.
Meanwhile, the demand for treatment is huge since most CLP
patients have not had bone grafts and dental restorations as of yet.
With the desire to implement the implant technique for CLP
patients in Vietnam and perform a systematic scientific research,
we conducted the thesis "Dental implant placement on alveolar
bone grafted patients after cleft lip and palate reconstructive
surgery".
II. RESEARCH OBJECTIVES
1. Evaluate jaw bone condition after alveolar cleft bone graft
2. Evaluate the success of implant treatment.
III. MEANING
4
The thesis provides a new treatment method for patients with
cleft lip and palate defect, not only torecoverthe function but also
to meet the aesthetic demand helping patients communicate

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
5
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

health of the arch and facilitates closing of the fistula in the
secondary bone grafting [138].
1.2.2. Flap preparation forgrafted recipient
Flap designs in alveolar cleft bone graft surgery are extremely
important to determine the success of the surgical procedure as it
provides adequate soft tissue for the closure over the bone graft
without flap tension and dehiscence. There are many flap design
techniques such as thelateral sliding flap, the oblique sliding flap,
the buccal finger flap, the nasal lining flap and the palatal flap
[18].The flap designs can be used by single or multiple
techniques, depending on the clinical situation for optimaltension-
free closure.
1.2.3. The choice of donor site for graft material
Autogenous bone can be taken from many different sourcesin
which the tibia is first used, followed by iliac crest, ribs, chin and
calvarial bone (SindetPerdersent and Enermark 1988) [116]. Some
authors have done a lot of research in order to replace the
autogenousbone material in alveolar bone grafting,such as with
demineralized freeze-dried bone combined with iliac cancellous
bone of Steven (2009) [121], β Tricalxium-phospate (TCP) of
Ruiter (2012) [107] or BMP-2 (bone protein) of Dickinson (2008)
[39] but studies using these materials is still not advancedand is
not commonly applied. Therefore,autogenousgrafted bone is still
6
considered as the golden standard for graft material of alveolar
cleft recovery.Ananth’s research (2005) summarized 110 centers
with 240 CLP surgical teams, which showed iliac crest bone is
still the most popularmaterial used by 83% [19].
1.2.4. Techniques of placing grafted bone
There are many techniques in placing the grafted bone in 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)

[24] using periapical radiographyand Kindelanscale (1997) [71]
using occusal radiographyto assess the bone heightbetween the
teeth in the cleft areas, successful results was obtained when more
than 50% bone fill in the cleft areas (Figure 1.16).
Thesescales are popular because it is easy to apply in
comparison with Long scale [81] and Witherow scale [140].
1.3.DENTAL IMPLANT
Osseointegratedimplant that was developed by professor
Branemark in the 1960s has now becomeconventional treatment
method to restore the missing teeth as well as congenital teeth
deficiency in CLP patients. In 1991, Verdi [139] reported a first
case of successful alveolar bone grafting and implant treatment,
then followed by some reports of implant treatment in similar
situation as Fukuda (1998) [50], Kearns (1997) [68], Lilja (1998)
[79], Takahashi [130], [131], Implants have the supported
fixationcomponent whichauthors have developed many flexible
solutions for implant prosthesesfor various and complex situations
of CLP patients after alveolar cleft bone grafting. However, most
of the above studies have evaluated the success of implant
osseointegration, not the aesthetic of implant prostheses.
Chapter 2: RESEARCH OBJECTS AND METHOD
1.1.Research subject
8
- Patient selection criteria: Patients over 15 years old, in good
health for endotracheal anesthesia, already has had palatoplasty,
complete unilateral alveolar cleft, lack of permanent tooth germ in
the cleft andhas not had any alveolar cleft bone graft.
- Elimination criteria: No alveolar cleft, no unilateral or bilateral
alveolar cleft.Patientswho disagree to participate in the research.
1.2.Research method

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

3
. Afterthat, hemostatic sponge was placed and 2 layer
sutures were used:periosteum suture and subcuticular suture. The
bone blocks were kept in a small stainless steel cup in saline for
moisture preservation.
1.3.2. Alveolar cleft bone graft surgery:
Flap design: The incision began at the edge of the cleft and
wentover the cleft’s perimeter,divided the cleft into 2 parts, then
went down to the alveolar crest, moved to the two sides ofthe
teeth’s neck next to the cleft and thencontinued to follow the
gingival contours to the distalof tooth #4 or #5 and upwardto the
vestibularforming avertical incision. At the top of the vertical line,
an incision was made with the vertical line ofangle 120° to easily
slidethe flap to the lateral and downwardposition (Figure 2.28).
After that, from the incision on the alveolar crest that stayed
closely to the neck (lateral) of the two teeth adjacent to the cleft,
the incision was continued along the gingival sulcus on the labial
side to the teeth at the two sides of the cleft.
The nasal flap closure began with the suture from the buccal
to the labial at one side of the flap edge, then the dissection was
continued from the labial to the buccal at the contralateral flap
edge. Finally, the knot was made (Figure 2.29).
Based on the bone grafting technique of two lateral cortical
10
bone plates from the symphysisby Tadashi Mikoya(2010) [127],
we introduced two iliac corticocancellousblock grafting
techniques in this study with the technical steps as follows:
Figure 2.32: The bone block on the vestibular was secured by screws
Figure 2.33:
Wound closure

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).
11
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

cortex;In the apical-coronal dimension, the implant shoulderis a
distance of 3mm from the free gingival margin;In the mesial-
distal dimension, the implant has a distance of at least 1.5mm
from the next root.
+ Prosthodontics: 6 months after the implant placement, secondary
surgery of gum opening was carried outfor inserting the healing
screws, then 3 weeks later, the impression is done for the
prosthodontics.
1.4.Assessment criteria
1.4.1. Soft tissue condition at the recipient site
- Good: pink mucosa, dry, tight and healing scar
- Average: dehiscence but nograftexposure.
- Bad: infection,dehiscenceorbone graftexposure.
1.4.2. Oronasal fistula
- Closed: Clinical examination showed the fistula was closed.
- Unclosed: Clinical examination showed the fistula still exists.
1.4.3. Assessment of alveolar bone graft
- Assessment of bone bridge formation by
periapicalradiography
12
Enermark scale was used for assessing bone formation in the
cleft[42] according to 4 levels:
• Type I: 75% - 100% bone recovery compared to the initial
bone graft site.
• Type II: 75% - 50% bone recovery compared to the initial
bone graft site.
• Type III: 25% - 50% bone recovery compared to the initial
bone graft site.
• Type IV: 0% -25% bone recovery compared to the initial
bone graft site

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.
13
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.

- Assessment of the implant prosthesis’saesthetic:
+ Following pink esthetic score (PES) and white esthetic score
(WES) based on Belser’s standard (2009) [23]: The pink esthetic
score assesses the soft tissue condition around the implant through
5 factors compared to the contralateral tooth: mesial papilla, distal
papilla, curvature of the facial mucosa, level of the facial mucosa,
and root convexity, soft tissue color. White esthetic score presents
the esthetic of the implant restoration with 5 parameters in
comparison with the contralateral reference tooth: general tooth
form, volume of the clinical crown; color, surface texture and
other characterization. A maximum total score WES and PES of
more than 12 was set for being esthetically successful, a score of
12 for clinical acceptance and a score of under 12 for
estheticalfailure.
+ Assessment of the degree ofpatient satisfaction by the score of 1
to 9 with a score of 1, 2, 3 for unsatisfactory, a score of 4, 5, 6 for
satisfactory and a score of 7, 8, 9 for above satisfactory [43].
Chapter 3: RESEARCH RESULTS
14
3.1. Clinical characteristics of the study sample
- Total of 32 patients with the average age of 20.2 (15-29), 23
females and 9 males in which 23 had left-side UCPL and 9 had
right-side UCLP. 100% of patients presented with an oronasal
fistulaand misalignment. Therefore, all patients required
orthodontic treatment with the average time of 12.5 months for
treatment.
- The occlusion of Angle Class I was found in 53.1% patients, Angle
Class III in 28.1% patients, the occlusion of cross bite, edge to edge or
open bite in the anterior but Angle class I in the posterior was reported
in 18.7%. Each patient had 9.8 decay on average.

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
15
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

(90.6%)
0 3
(9.4%)
0 32
12 months 29
(90.6%)
0 3
(9.4%)
0 32
15 months 29
(90.6%)
0 3
(9.4%)
0 32
18 months 28
(87.5%)
1
(3.1%)
0 3
(9.4%)
32
p= 0.764
3.2.2.2. Result of bone formation using CT Cone Beam
On axial CT at 6 months postoperatively, the mean apical-
coronal distance of 11.4.0±2.4 mm and the mean buccal-lingual
distance of 6.1±1.0mm was reported. According to Renouard’s
standard [47], 29 of 32 alveolar clefts (90.6%) displayed thebone
bridge formation enable for implant placement. 3 clefts
(9.4%)showed insufficient bone for implant placement which
indicated fixed bridge restorations.

9,4%%
0%%
3.3. Result of implant placement
16
- 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

surgery
Post
implant
surgery
Success
Satisfact-
ory
survival
Compro-
mised
survival
Failure
12
months
6
months
32
(100%)
0 0 0 32
(100%)
15
months
9
months
32
(100%)
0 0 0 32
(100%)
18
months

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
17
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

Post
implant
surgery
Esthetical
success
Clinical
acceptance
Esthetical
failure
15
months
9
months
18
(56.3%)
5
(15.6%)
9
(28.1%)
32
(100%)
18
months
12
months
18
(56.3%)
5
(15.6%)
9

(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

Satisfied
Unsatis
-fied
15
months
9
months
21
(72.4%)
8
(27.6%)
0
29
(100%)
18
months
12
months
21
(72.4%)
8
(27.6%)
0
29
(100%)
Chapter 4: DISCUSSION
4.1. The characteristics of the study sample
In our study, all 32 patients presentedwith teeth around the
cleft misalignment. The occlusion Class III Angle was 28.1%
while Class III Angle in normal patients without defects in Dong

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,
19
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

restoration. However, according toDempf’sresearch [36], the
alveolar ridge height after intermediate secondary bone
graftingwas reported be lower than after late secondary bone
grafting (tertiary). This was a challenge we had to face in this
study becauseinsufficient bone height would affect the implant
stability and the restorations’ aesthetic [36]. Therefore, to
20
overcome this difficulty, we performed additional bone grafts for
all cases in implant placement.
4.3. The technique of the alveolar bone graft
Based on the technique of a cortex bone plate (CBP) along
the lining of the palatal suture line [85], especially lateral cortical
bone plates from the symphysis [127], we have modifieda two
iliac corticocancellous block graftin alveolar bone grafting. With
this new technique, screws were used to fix the bone graft in the
vestibular side. Compared with Tadashi’s technique, the symphisis
cortical plates are just inserted on the cleft, while according to
Buser (2009), the fixation of the graft is definitely an important
factor for the successof bone grafting techniques [28]. In the
technique of two iliac corticocancellous blocks, we combined the
rigid mechanical properties of cortical bone that limit bone
resorption and easily obtain the implant initial stability and the
advantages of cancellous bone that provide rapidly vascularization
and long-term success. We chose iliac crest as donor site as it
provides a large volume of corticocancellous bone with low
morbidity. Also, it shortens the number of surgeries and lower
healing time in case of bilateral cleft while Tadashi
usingmandibular symphysis with limited quantity required a 2
step procedure for bilateral clefts.
4.4. Result of alveolar bone graft

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.
21
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,

palatal flap and mucoperiosteumrelease for tension free sutures
and adequate blood supply; and early implant placement (4 to 6
months after bone graft) maintained bone graft results and maybe
follow-up period of our study was shorter than the above-
22
mentioned studies that complications and bone resorption have
not happen yet.
Bone volume was reconstructedon the CT scan, the apical-
coronal distance was 11.4 ± 2.4 mmand the buccal-lingual distance
was 6.1 ± 1.0 mm. Of 32 patients underwent the bone graft, 29
patients hadbone reconstruction in the apical-coronal distance of
over 10mm and in the buccal-lingual distance of over 5mm, 3
patients with bone reconstruction in the apical-coronal distance
were under 5mm and in the buccal-lingual distance were under
4mm. Meanwhile, following the criterion of successful implant by
Franck Renouard (1999) [47],the minimum apical-coronal distance
of bone must is7 mm and the minimum buccal-lingual distance is
4mm. Thus, combining these two distancesshowed that 29 patients
(90.6%)were enable for implant placement. This result is
consistent with Takadashi’sstudy(1999) that sufficient bone for
implant within 6 months after bone grafting presented in 90% of
cases,after 6 to 24 months was 80%, after 24 months was 44% and
over 5 years was only about 40% of cases [131].
4.5. Result of implant placement
4.5.1.Result of implant osseointegration
Our results of 90.6% implant survival was equivalent to
Yoshiro Matsui’s study (2007) that reported survival rate of
implant was 98.6% [144], or Samuel’s (2010) [110].The results
was higher than Hartel’s (1999) [57] or Kramer’s (2005) [74].
We obtained such a good result that can be explained by

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
23
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

estheticalfailures(score <12). Based on the assessment of
clinicians, 71.9% of the implant prostheses were clinical
acceptable and 28.1% were esthetical failures.
Theseunsatisfactory results were explained probably by 2
24
following reasons: Firstly, our subjectswere cleft lip and palate
patients who possessed complicated and unfavourable initial
clinical condition such as alveolar cleft existence, a most serious
bone defect among horizontal or vertical bone defect in noncleft
patients;insufficient bone height after bone graft still occurred in
this kind of cleft (the wider the cleft is, the greater the bone
shortage is), especially in late secondary bone graft (over 16 year
olds);the soft tissue margin ofthe tooth adjacent to the cleft was 1
to 2mm discrepant compared with the contralateral tooth [43]
which is why the crown on the implant and the tooth adjacent to
the cleft is usually longer than the contralateral tooth and the
absence of the gum papilla causing anaestheticappearance that
was unavoidable. Second reason wasthat currently there’s no
exclusive aesthetic evaluation standard of prostheses on implant
for cleft lip and palate patients.
All aesthetic evaluation criteria for restorations on implants
including Belser standards are based on the single tooth
replacement in noncleft patients. Applying the aesthetic
evaluation criteria of normal patients with no malformations
(simple condition) oncleft lip and palatepatients (complicated
condition) is not appropriate because there is no similarity
between these two subjects. This is probably the reason
thatmostcliniciansjust evaluated the outcome of implant
osseointegration rather than the aesthetic of restorations in studies
of bone grafting and implant restorations for patients with cleft lip

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.

Thus, the grafting technique of 2 iliac corticocancellousblock
have contributed a new method showing good results in alveolar