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ORAL REHABILITATION WITH ALVEOLAR DISTRACTION and DENTAL
IMPLANTS in PATIENTS WITH CELIAC DISEASE: Literature review and case
report
ABSTRACT
Celiac disease (CD) or glutensensitive enteropathy is characterized by small intestinal
mucosal inflammation, villous atrophy and crypt hyperplasia which improve with a gluten
free diet. It has long been recognized that CD may affect the skeletal system and may cause a
decrease in bone mass and alterations in bone metabolism, but the pathogenesis of
osteoporosis associated with CD is not well understood. The present case describes the use of
dental implants and alveolar distraction osteogenesis to promote the formation of new bone
and soft tissue in a large, severely resorbed segment of mandibular alveolus of a patient with a
CD. The primary implant stability, osseointegration were achieved at all implant fixture sites
and 5 years follow up period. We have suggested these procedures in patients with CD treated
only by strict glutenfree diet.
Key words: Celiac disease, alveolar distraction, dental implants, bone mineral
density, osteoporosis, glutensensitive enteropathy
ÖZET:
Çölyak hastalığı veya gluten sensitif enteropatisi ince bağırsağın enflamasyonu, villus
atrofisi ve glutensiz diyetle iyileşen kript hiperplazisi ile karakterizedir. İskelet sistemini
etkileyebildiği ve kemik metabolizmasında değişimlere ve kemik kütlesinde azalmaya neden
olabildiği bildirilmesine rağmen osteoporözün patogenezindeki rolü tam olarak
açıklanamamaktadır. Çölyaklı bir hastada aşırı rezorbe mandibulada yeni kemik ve yumuşak
dokunun oluşturulmasında distraksiyon osteogenezi ve dental implantların kullanıldığı vaka
sunulacaktır. İmplant stabilitesi ve osseointegrasyonun izlendiği ve 5 yıllık takibi yapılan
hastadan elde edilen veriler ile sadece glutensiz diyet uygulanan vakalarda bu tip cerrahi
işlemlerin uygulanabileceğini önermekteyiz.
Anahtar Kelime: Çölyak hastalığı, alveolar distraksiyon, dental implant, kemik mineral
yoğunluğu, osteoporöz, gluten sensitif enteropati
INTRODUCTION
Celiac disease (CD) or glutensensitive enteropathy, is a condition related to the
small intestine’s intolerance to gluten and its constituent compound gliadin, which are
highmolecular weight peptides found ubiquitously in wheat, rye, oat, and barley
products1,. It is characterized by small intestinal mucosal inflammation, villous atrophy
and crypt hyperplasia which improves with a glutenfree diet2,3. Recent epidemiologic
data have shown a prevalence of CD approaching 1% in the general population4. CD in
adults shows a peak in the fourth and fifth decades for women, and a peak in the sixth
and seventh decades for men5, the female to male rate is approximately 7:16.
Oral involvements consists of dental enamel defects in permanent teeth of 50
80% of adult patients, delayed eruption, mucosal inflammatory changes like recurrent
aphthous ulcers and angular cheilitis7,8. It has long been recognized that CD may affect
the skeletal system and cause a decrease in bone mass and alterations in bone
metabolism. The mechanism of underlying bone alterations in CD is thought to be
secondary to calcium malabsorption leading to increased parathyroid hormone secretion,
which in turn, increases the bone turnover and cortical bone loss9. Although glutenfree
diet promotes a complete recovery of bone mineralization in patients with CD, 40% of
treated patients with glutenfree diet have bone mineral density below the normal mean10.
Fracture repair and osseointegration of biomaterials such as titanium used for orthopedic
or craniofacial reconstruction have similar responses in host tissue, since both of them
require bone regeneration in damaged tissue11.
1
Over the past decade, distraction osteogenesis has become increasingly popular
and has been applied to maxillofacial region. More recent clinical reports have shown
that alveolar distraction osteogenesis is effective for treating severe forms of alveolar
atrophy12, the advantages of vertical distraction osteogenesis compared with conventional
techniques are the decreased resorption tendency, no requirement for bone harvesting,
lower morbidity, lower infection rate, and early insertion of implants13.
The present case describes the use of dental implants and alveolar distraction
osteogenesis to promote the formation of new bone and soft tissue in a large, severely
resorbed segment of mandibular alveolus of a patient with a celiac disease. To known our
best knowledge this is the first case with celiac disease treated with alveolar distraction
and dental implants.
2
CASE REPORT
A 44 years old female with a CD was referred to our clinic for prosthodontic
rehabilitation. Past medical history revealed that the patient was first diagnosed with CD
at 22 years old and since then she had a strict glutenfree diet and in premenopausal
period. Patient’s height was 150 cm and weight was 52 kg. The bone mineral density
(BMD) measured at AP spine L1L4 was 1,072 g/cm2 with a Tscore of 0,6. Bone
density was up to 10% below young normal. Patient was considered normal according to
World Health Organization (WHO) criteria which the patient had low fracture risk. The
BMD measured at femur was 0,731 g/cm2 with a Tscore of 2,2. The patient was
considered osteopenic according to WHO criteria and bone density was between 10 and
25% below young normal, which had moderate fracture risk and advised treatment.
Effective treatment consisted of oral bisphosphonates and Evista and an adequate intake
of dietary calcium and vitamin D.
Intraoral examination showed that mandibular alveolar ridges were thin and there
was adequate maxillary structure for the complete upper denture. The depth of vestibular
sulcus was decreased and the overlying mucosa was normal (Fig 1). Both panoramic
radiograph and three dimensional CT confirmed moderate bony height in anterior
mandible (Fig 2,3). The treatment consisted of the alveolar distraction in anterior part of
mandible with a implant supported prosthesis and 8 dental implants and fixed prosthesis
in maxilla.
The operation was performed under deep sedation and local anesthesia. A
horizontal incision was made in the buccal vestibule to expose the bone by protecting the
3
gingiva covering the crest of the ridge and maintaining the attachment of the lingual
mucoperiosteum to the transport segment. The periosteum on both sides of the incision
was dissected superiorly and inferiorly to enable preparation of a bone segment more
than 6 mm high. A boxshaped osteotomy that included the lingual cortex was performed
using an oscillating saw and osteotomes. The transport segment was mobilized freely yet
remained attached to the lingual mucoperiosteum. Once the distractor had been fixed to
the alveolus in the planned position, the distractor was activated, raising the transport
segment to confirm adequate mobility, appropriate direction of movement and absence of
osseous interferences between the transport segment and the basal bone. The transport
segment was then returned to its original position and then closed the flap primarily. The
patients were prescribed a week of antibiotic treatment (amoxycillin 500 mg three times a
day), analgesic (Naproxyen sodium, 275 mg twice a day) and 0.25% chlorhexidine rinses.
After 7 days of latency period, bone lengthening was started at a rate of 0.7 mm/day (two
full revolutions of the rod). After 10.5 mm transport was achieved, the distractor was left
in place for 12 weeks. Continued bony maturation during the consolidation period was
evident on the panoramic radiographs and CT (Fig 4,5). After the period of consolidation,
the distractor was removed and implants were placed in maxilla (Fig 6). No
complications including dehiscence, infections, or alveolar pedicle lesions were observed
in the postoperative period. Patients felt no pain during the activation of the distractor
device. The soft tissues displayed good trophism and the alveolar ridges proved suitable
for implantation at the end of distraction (Fig 7). At the end of distraction period patient
was in menopausal period. The regenerate zone appeared on the panoramic radiograph as
4
hyperdense, hypermineralized bone. Two implants (3.3 diameter and 13 mm in length,
Swiss plus, Zimmer, USA) were placed bicortically in the transported segment and the
mandibular basal bone. In maxilla, 8 implants (3.7 and 4.1 diameter and 13 and 15 mm in
length, Biolock, USA) were placed (Fig 8). Implant supported removable prosthesis was
made after 3 months for mandible and fixed prosthetic restorations for maxilla (Fig 9,10).
Clinical and radiographic findings showed that the implants remained stable under
functional loading and no signs of implant failure during 5 years of follow up period.
5
DISCUSSION
The onset of celiac disease is often silent14 and an untreated celiac disease can
affect other body systems including the blood, skeletal, endocrine, neurologic and
reproductive systems5. Mazure et al. reported that reduced bone mineralization occurs in
asymptomatic celiac patients before any other symptoms become evident15. Several
studies have showed that more than 75% of untreated adult celiac suffer from a loss of
bone mass15,16 and 3% of them has osteoporosis17. The pathogenesis of the osteoporosis
associated with CD is not well understood but it might affect the skeleton through several
mechanisms. It is shown that calcium deficiency in patients with untreated CD is due to
both primary and secondary calcium malabsorption caused by villous atrophy18. Vitamin
D malabsorption is probably of less significance. It is also reported that the main
associated variables of low bone mineral density were age, low serum vitamin D level,
low body weight and postmenopausal status19.
There is now evidence that CD is associated with defects of gonadal function in
both men and women, in whom CD can lead to amenorrhea and early menopause15,
which are associated with high risk for osteoporosis20. It is reported that postmenopausal
women had earlier menopausal age than controls20. The possible abnormalities of gonadal
function together with earlier menopause in women could have resulted in lower bone
mineral density21. The annual rate of decreases in bone mineral density values is faster in
postmenopausal women than in premenopausal women22. It has been shown that bone
turnover increases after the menopause and remains elevated there after23. When the
present case referred to our clinic she was in premenopausal period and had a strict
6
glutenfree diet for 22 years. The BMD measured at femur was 0,731 g/cm2 with a T
score of 2,2. The patient was considered osteopenic according to WHO criteria and bone
density was between 10 and 25% below young normal, which had moderate fracture risk
and advised treatment. Effective treatment consisted of oral bisphosphonates and Evista
and an adequate intake of dietary calcium and vitamin D. After alveolar distraction, she
was in menopausal period. The menopausal stage of female patient’s gains importance
from the view of oral and maxillofacial surgery and it should be taken into consideration
while planning the surgery. In the healthy bone, there is a good balance between the
amounts of resorbed bone and newly formed bone24. But in osteoporosis this balance is
disrupted. Morphologic changes in osteoporosis can be seen in both cortical and
trabecular bone. Cortical bone thickness decreased, which can lead to stress fractures and
trabecular bone will undergo osteoclastic resorption. As a result of these changes, the
density, stiffness, and strength of bone are decreased25. The changes in bone tissue
metabolism that may occur in the jaws are widely investigated and shown that the
metabolism seem to be the same as those detected in the long bones in both human26 and
animal studies27. These changes include, decreased bone mineral content and density,
microarchitectural deterioration of trabeculae, increased osteoblastic activity and
remodeling rate, reduction volume of the residual ridge and decrease in cortical thickness.
Although the changes in maxilla is more evident, the mandible is also affected28.
Mineralization is also decreased in bone undergoing high turnover because there is
insufficient time for complete maturation of bone matrix29. These factors contribute to the
problematic bone healing in osteoporosis. The principle mechanism underlying the
7
osseointegration process around implant is very similar to those occurring during bone
fracture repair and involves a cascade of various cellular and extracellular events30. It is
known that fracture healing is delayed with respect to callus mineralization and
biomechanical properties in steroid induced osteoporosis31. To date there is a lack of
conclusive studies to support an absolute contraindication for the placement of dental
implants in patients with osteoporosis. Several studies have observed that osteoporosis
decreases bone implant contact and biomaterial osseointegration is slower in osteoporotic
subjects, with an increased rate of prosthetic device failures both in dental and
reconstructive surgery30,32,33. While others have suggested osteoporosis is not a risk factor
for osteointegration of oral implants and this impairment causes no clinical implant
failure rate34,35. A recent review concluded that, while the presence of osteoporosis poses
potential additional risks for some reconstructive procedures, these patients have much to
gain from implantsupported reconstruction when faced with the alternative of removable
denture use and increased alveolar bone resorption. But it is wise to be cautious for the
patients with severe osteoporosis in the treatment planning for maxillary implants33. In
present case, the time of loading in implants was same as normal patients as six months
after the insertion of implants in maxilla. The primary implant stability, osseointegration
were achieved at all implant fixture sites and 5 years follow up.
Early diagnosis and treatment of celiac disease has been shown to decrease the
risk of osteoporosis26. It is mandatory to restore the small intestinal mucosa to normal so
that the mechanism that promote calcium and vitamin D absorption can be allowed to
function. Currently the only treatment for patients with CD is together with a calcium
8
rich and glutenfree diet. It is not completely clear whether metabolic bone disease in CD
is completely reversible21. Glutenfree diet does not always lead to improvements in bone
mineral density18. Moreover, bone mineral density values increased mainly during the
first year of followup partly along with weight gain37. Kemppainen et al indicate that
bone disease in CD patients can recover during the longterm glutenfree diet37. But some
reports found a low effect of the glutenfree diet for 1 year15, whereas others showed a
remarkable improvement of the bone mineralization for the same period in adults18,38.
This might be explained by the starting age of the patient to the glutenfree diet. In
addition to these a recent study showed that a glutenfree diet promotes a rapid increase
of bone mineral density that leads to a complete recovery of bone mineralization in
children and adolescents with CD and concluded that at least 4 years of glutenfree diet
are required for a complete recovery of bone mineralization in some patients39.
Distraction osteogenesis is the biologic process of new bone formation between bone
segments gradually separated by incremental traction13. During the distraction period to
generate bone tissue, local progenitor cells are likely recruited for proliferation and
differentiation into osteoblasts. This process is vasculardependent and requires the
maintenance of adequate blood supply40.It was also reported that callus formation and
remodeling occurred later in osteoporotic rabbits than in the control group, and the new
bone was more osteoporotic and osteoporosis associated with estrogen deficiency
adversely affects the outcome of callus distraction. Nonetheless, radiographic findings in
rabbits indicate that the effects may not be so great as to preclude clinical procedures41.
The consolidation period was 12 weeks in present case and regenerated bone was mature
9
enough and new bone formation was observed at the time of the removal of distractor.
The stability of implants both insertion and followup was good and no bony resorption
or any complications were noted.
In conclusion, the present case describes the use of dental implants and alveolar
distraction osteogenesis in the patient with CD at five years follow up. To the best of our
knowledge this is the first report of a patient with CD treated by this surgical procedure
and the rehabilitation with dental implants. We have suggested these procedures in
patients with CD treated only by strict glutenfree diet. Osteopathy’s due to CD have
increasing importance from the aspect of oral and maxillofacial surgery. Further studies
in this subject by using histological and histomorphometrical researches on bone healing
and architectures in CD patients and longterm followup periods are essential for
understanding the effects and success rate of oral dentoalveolar surgery in patients with
CD.
10
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15
Figure legends
Figure 1: Preoperative intraoral view
Figure 2: Preoperative 3D view of anterior part of mandible on CT
Figure 3: Thin, insufficient weight and height of anterior mandible
Figure 4: Postoperative panoramic view of patients with alveolar distraction and
dental implants in maxilla
Figure 5: Postoperative 3D view of anterior mandible on CT
Figure 6: The mature bone formation on distraction site
Figure 7: Postoperative intraoral view
Figure 8: Postoperative panoramic view of dental implants in both jaws
Figure 9: Fixed prosthesis in maxilla and ball attachments in anterior mandible
Figure 10: Final appearance of patient
16
Figür 1
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Figür 3
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Figür 5
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