Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I’m Bill Klaproth, and with me is Dr. Sal Ruggiero, who is here to discuss navigating dental implants in challenging cases. Dr. Ruggiero, thanks for being here. 

Dr. Sal Ruggiero: Thanks. My pleasure, Bill. Thank you. 

Bill Klaproth (host): Always great to talk with you. So, let’s jump into this. So first off, it might be good to set the stage for this. Could you explain to us, what are dental implants? 

Dr. Sal Ruggiero: Well, dental implants are not unlike any other implant. It’s a titanium cylinder with threads on it that allows the dental professional to insert or to restore a missing tooth site with some fairly good and long-term results. It really was a result of some basic orthopedic research many, many years ago by Dr. Branemark where he noted that certain types of bone chambers that he was using to study the biology of bone and how bone heals that they couldn’t take the titanium chambers out of the bone, they actually integrated. And so, this kind of set off a little light bulb in his head and at that point in time, the concept of the dental implant, the integrated titanium dental implant was born. And it has really blossomed into one of the most significant contributions that a dentist and an oral surgeon can have and make for patients. 

Bill Klaproth (host): Absolutely. Dental implants significantly improve a patient’s quality of life, there’s no doubt about that. So, since we’re talking about navigating dental implants in challenging cases, Dr. Ruggiero, can dental implants be used in patients with cleft lip and palate? 

Dr. Sal Ruggiero: Sure. In fact, we use dental implants in these patients all the time. The most common scenario, especially in cleft lip and palate patients, is for the replacement of the lateral incisor, which in cleft patients is commonly either missing or malformed. And so just imagine that the space where the lateral incisor would be is now empty with no tooth there. And if the bone is of adequate size and good quality then one could consider replacing the lateral incisor with a dental implant. So there are some criteria that we have to use and some clinical scenarios that we have to take into consideration. But for the most part, that could be considered without any issues. 

Bill Klaproth (host): So, what are some of the challenges then of placing dental implants in cleft lip and palate patients? 

Dr. Sal Ruggiero: There are several. As I mentioned before, the success of a dental implant relies on two major factors. That’s bone quality and bone volume. And typically in a cleft patient, they will have required an alveolar bone graft to close the fistula that’s present. This could be be unilateral or bilateral. In some patients, although they don’t have a fistula, they have very poor quality of bone that’s there, volume-wise more than quality. So, they need some type of augmentation. So, if the bone graft can be of sufficient size and quality to maintain the site of the lateral incisor, then that could be used to place a dental implant. The other variable here is age. We have to time the grafting of the alveolar cleft based on the development of the canine. Even though the graft heals well, and you have good volume, you really have to wait for the patient’s craniofacial growth to be completed before you consider an implant. The other issue is soft-tissue concerns. Oftentimes patients will have either deficiency of soft tissue or the quality of the soft tissue in the cleft site might not be the best in the sense that it needs to be keratinized rather than non-keratinized tissue. So, these are things that we have to address before placing implants. But in general, if the space is maintained for the lateral incisor, and bone quality is good, then patients with clefts can have implants in these positions. Now, the other alternative is to not place a dental implant in the cleft patient even though the bone is of good quality and sometimes, based on the clinical scenario, the canine can actually be moved into the lateral position, orthodontically. And that can serve as a reasonable solution as well. But again, this becomes a case-by-case selection. 

Bill Klaproth (host): Absolutely. So, in addition to replacing missing teeth and improving dental function, can dental implants improve speech in cleft lip and palate patients? 

Dr. Sal Ruggiero: Sure. Consider that there will be a space in the anterior maxilla where the lateral incisor isn’t. So, if you replace that missing tooth with a dental implant and provide that tooth back into the arch, then yes, you will improve speech. They won’t have a lisp anymore. I mean, there’s also a prosthetic solution. Patients could have bridges or removable appliances that can also accomplish the same thing, and that is an option as well. But yes, once you close that space with a dental implant or any other prosthetic device, then that should improve the speech as well. 

Bill Klaproth (host): So, is the success rate of dental implants in cleft lip and palate patients comparable to that in regular cases? 

Dr. Sal Ruggiero: Well, I would say that if the playing field is level, meaning that the quality and the quantity of bone at the cleft site when you want to place an implant is good, then I would say that success rates are as good as someone who didn’t have a cleft. 

Bill Klaproth (host): That’s really great information, Dr. Ruggiero. So, thank you for talking about that. As we’re talking about navigating dental implants in challenging cases, certainly cleft patients certainly provide that challenge. Let’s move on to teenagers now. Are teenagers eligible for dental implants and what are the considerations? 

Dr. Sal Ruggiero: Yes, but it really depends upon the craniofacial growth, as I had mentioned before. What you don’t want to do is place an implant into a growing patient because what’ll happen is if you place the implant into the position you want it to be in and the dental arch and the craniofacial skeleton continues to grow, that growth is typically in the upper jaw and lower jaw is forward and down. It’ll seem as if the implant is actually submerging over time as the bone around it grows. So that could be a real prosthetic challenge if that happens to use that implant again. So, what we typically will do is wait until the patients are fully grown from a craniofacial standpoint. And in that interim period where they don’t have the tooth there, they can consider other alternatives. Prosthetic alternatives like a removable prosthetic appliance or even a cemented appliance until they reach the point in time where their dental arch has finished growing. 

Bill Klaproth (host): So, it’s crucial that the jawbone has finished growing before placing an implant. 

Dr. Sal Ruggiero: That’s correct. 

Bill Klaproth (host): What are some unusual dental implant situations in teenagers then and how are they handled? 

Dr. Sal Ruggiero: Some of the clinical scenarios where there’s trauma is involved, where let’s say you lose your front tooth in a sporting accident or something of that nature, then it’s tempting to place an implant in a 13-year-old that has a missing central incisor. But in those scenarios, you know, you really would need to just perhaps graft the site and plan for a prosthetic solution. The other scenario would be in patients who have, let’s say, congenitally missing teeth. Lateral incisors are probably the most common congenitally missing tooth. That could be a challenge to restore, even though they have bone present. The bone is typically not of good volume. So, what we need to do again is to find a prosthetic solution for them until they get a little older, and then we can consider grafting those sites, providing the adequate volume, and then proceeding with implant placement. They can also consider a prosthetic solution, like conventional bridges. But I would, I think the ideal treatment would be to replace it with a dental implant. 

Bill Klaproth (host): So, temporary solutions make sense until the patient is old enough for implants. So, let’s move on to people with oral cancers. Can individuals who have undergone treatment for oral cancer potentially receive dental implants as well? 

Dr. Sal Ruggiero: Yes, but there are several variables that we have to consider. The biggest one is have they had any radiation treatment to address their cancer? And there are some, plenty of papers that have looked at the survivability and the outcomes of implants placed into the irradiated mandible and maxilla. And it’s a little bit of diverse opinions as an outcome. Some say some reports suggest that there are good outcomes. Others say that there are some not so good outcomes. Now, the problem with the literature is that they never account for all the variables that need to be accounted for, such as radiation dose and portals, which are very important things. So, I would submit to you that if the radiation in the area that you are considering to place an implant is low or if the site is not within the field of the radiation therapy, then they can have an implant placed without any issues. Oftentimes we get some insight into whether or not a patient can receive an implant by virtue of the fact that they’ve had perhaps let’s say a tooth extracted in that same site recently and if that site healed uneventfully, then that’s a good litmus test for implant success. It’s in all likelihood that’s going to be okay. So yes, you have to consider radiation therapy and it may very well play a role depending on the dose of the radiation therapy and the portal of therapy, where what portion of the jaw received irradiation treatment. The other variable is, of course, which jaw. The upper jaw seems to be a little bit more radioresistant and probably less likely to have an implant failure than the lower jaw. Whether or not they are commonly receiving chemotherapy. Certain medications that are, these antimetabolite and these chemotherapy agents can have a profound effect on bone healing. And so you have to you have to factor that in as well. 

Bill Klaproth (host): So Dr. Ruggiero, in all three of these cases, the cleft lip and palate patients, teenagers, people with oral cancer, it sounds like the key is for patients to have a plan. Why is that important? 

Dr. Sal Ruggiero: It’s important because we have to do a risk-benefit analysis of whether or not these patients can receive implants and to maximize their chances of having a positive outcome. And so what that means for the cleft patient is to wait until they’re of age and they maximize the amount of bone you can place in that cleft site. In patients who are younger who may have congenitally missing teeth, we just have to, again, find a prosthetic solution sooner for them and then wait till they grow. In patients with cancer, we have to have a discussion with the radiation therapist and have an idea of what their radiation dosages are. And then we make a decision based on what we believe to be a safe and reliable implant procedure that will give them back the teeth that they’ve lost. And in these scenarios, it also is very important to get the patients and the patient’s family involved so they can be involved in this shared decision-making model as to whether or not an implant is the best choice for them. 

Bill Klaproth (host): So, weighing those risks and benefits and the feasibility of dental implants in each specific case, and like you said, getting the family involved as well. That all makes sense. So, really important to have a plan. As we wrap up, Dr. Ruggiero, thank you so much for your time. One last question, anything else you want to add as we talk about navigating dental implants in challenging cases? 

Dr. Sal Ruggiero: The only other scenario which has become common nowadays is the placement of dental implants in patients who are receiving medications for osteoporosis or are receiving these anti-resorptive therapies for cancer. It falls in almost the same algorithm as those patients who are receiving radiation therapy, almost. But for the most part, I think patients who are receiving these anti-resorptive medicines for osteoporosis for the most part, can have dental implants without much concern about having failures. For those patients who are receiving the anti-resorptive therapies for let’s say metastatic disease within the bone and are receiving higher doses, those patients I believe are at an elevated risk of developing real problems. So, they probably should shy away from implants in that cohort of patients. There will be a consensus guideline international review paper, probably in Osteoporosis International, that will be coming out within the next several months that will provide some guidelines as to what the risks are in placing implants in these patients. 

Bill Klaproth (host): Good considerations to remember, certainly. Dr. Ruggiero, thank you so much for your time. This has really been interesting. We appreciate it. 

Dr. Sal Ruggiero: My pleasure. 

Bill Klaproth (host): And once again, that is Dr. Sal Ruggiero. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, please share it on your social media and don’t forget to subscribe. Thanks for listening.