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Vertical distraction osteogenesis of the alveolar process for implant

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					                                                                                  Q U I N T E S S E N C E I N T E R N AT I O N A L




Vertical distraction osteogenesis of the alveolar
process for implant therapy: Two case reports
J. Thomas Lambrecht, Prof, Dr Med Dent1/
Manuela Linder, Dr Med Dent1/Sinisa Ostojic, Dr Med Dent1


Rehabilitation of the chewing function of a patient depends on the quality and volume of
the existing jawbone. Vertical augmentation of the jawbone is often a challenge for the
dental surgeon. Various transplantation methods, from transplantation of autogenous
bone to use of bone substitute material, have been described and discussed and are
often controversial. Vertical distraction presents an alternative to preimplantation augmen-
tation of vertically reduced bone. The technique offers certain advantages over conven-
tional augmentative methods. (Quintessence Int 2007;38:859–866)


Key words: alveolar process, distraction, implants, osteogenesis, vertical bone deficiency




The vertically reduced alveolar process pres-                      free bone transplants leads to higher mor-
ents a challenge to the dental surgeon.                            bidity and can cause some bone resorption.
The success of the prosthetic procedure de-                        Relatively small defects can be treated with
pends on an adequate height and width of                           guided bone regeneration therapy. Allo-
the implantation bed and the quality of the                        plastic material cannot be used as an implan-
bone. Some of the reasons for vertical reduc-                      tation bed.
tion of the alveolar process are trauma,                               Bone transplantation, in combination with
tumors, congenital deformations, and jaw                           simultaneous or delayed insertion of implants,
atrophy caused by tooth loss.                                      is usually the treatment of choice for a larger
   There are 2 types of augmentation: hori-                        defect. The bone is usually taken from the cor-
zontal- and vertical-ridge augmentations.                          ticospongious pelvic span.2,4 Researchers
Elaborate techniques for the augmentation                          recognized quite early the problems associat-
of the alveolar process include free bone                          ed with this method in the area from which
transplants,1,2 controlled bone regeneration,3                     the bone is taken.5,6 Extraction morbidity is
and use of alloplastic materials. The use of                       a significant factor for the determination of
                                                                   the clinical indication and limits patient
                                                                   acceptance of this method. The experiences
                                                                   of Bloomquist and Turvey7 showed that
1
University Hospital of Oral Surgery, Oral Radiology, and Oral      patients considered the subjective adverse
Medicine, University of Basel, Basel, Switzerland.
                                                                   postoperative effects at the area where the
Reprint requests: Prof Dr Dr J. Th. Lambrecht, University
                                                                   bone was taken to be more significant than
Hospital of Oral Surgery, Oral Radiology, and Oral Medicine,
University of Basel, Hebelstrasse 3, CH-4056 Basel, Switzerland.   the adverse effects that resulted from the pro-
Fax: +41-61-267 2607. E-mail: J-Thomas.Lambrecht@unibas.ch         cedure at the cerebral cranium.




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                                                                                                                                   Removal of
                                                                                                                                   distractor +
                                                           Operation                                                              implantation



                                                                         7 days            3    0.3 mm/day          12 weeks



                                                                    Latency phase              Distraction        Consolidation



Fig 1 Intraoral distractor 1.0 and the corresponding    Fig 2   Treatment plan for distraction osteogenesis.
drill.




                           Distraction osteogenesis offers an alterna-           The microplates are buccally and eccentri-
                       tive augmentative procedure. Orthopedic                cally affixed to the bone with screws (Centre
                       physicians and trauma surgeons have been               Drive, Martin) outer diameter of 1.0 or 1.5 mm).
                       familiar with this procedure for many years. It        A 360-degree twist of the drive screw
                       was first described by Ilizarov.8 The distrac-         advances the 1.0 miniplates by 0.3 mm.
                       tion technique was used in the facial area by             Distraction osteogenesis is divided into 3
                       McCarthy et al9 and Klein10 to sagittally elon-        phases that drive the treatment plan (Fig 2).
                       gate hypoplastic mandible with an extraoral
                       device. Distractors in connection with intrao-         Case 1
                       ral devices were described by McCarthy et              A 16-year-old patient was referred for recon-
                       al11 and Wangerin.12 For several years now,            struction after losing mandibular anterior
                       osteodistraction in the craniofacial area has          teeth as a result of hematogenous osteo-
                       been a recognized procedure.13–18                      myelitis. Figures 3a and 3b show the preop-
                           Since the introduction of the distraction          erative radiographic and clinical views. While
                       method, it has been possible to locally dis-           the mental nerve was carefully protected, the
                       tract the alveolar ridge in preparation to             incision was made buccally in a curved man-
                       insert, as a second step, a bone implant. This         ner and under local anesthesia (Fig 3c).
                       article illustrates the technique with one                 To ensure the nutritional function of the
                       example for each the maxilla and mandible.             periosteum as well as possible, the bone in
                                                                              that segment should be exposed as little as
                                                                              possible and only to the extent necessary to
                                                                              place the distractor.
                       CASE PRESENTATIONS                                         Instruments are used to contour the mini-
                                                                              plates and to adapt them to the exposed
                       The vertical distractors used in this study            bone. Subsequently, the distractor is affixed
                       were made of titanium (Martin Medizin-                 with 1 screw per plate, and the osteotomy
                       technik) (Fig 1). The composition of the tita-         line is determined. The clinician then
                       nium alloy meets the requirements of the               removes the device and conducts the
                       American Society for Testing and Materials             osteotomy of the segment to be distracted
                       (ASTM) for surgical implantation applica-              (Fig 3d) using a thin Lindemann drill or piezo-
                       tions. Microplates were welded to the sliding          surgery. Subsequently, the distractor is
                       mechanism and can be adjusted to the                   affixed once again. The clinician verifies the
                       respective bone surfaces.                              trouble-free function of the alveolar process




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                    Fig 3a Preoperative panoramic radiograph showing a gap in the area
                    of the mandibular left lateral incisor and canine.




Fig 3b Intraoral situation with significant vertical   Fig 3c   Buccal incision.
and horizontal bone resorption.




Fig 3d Intraoperative situation with minimal bone      Fig 3e The distractor is fixed to the osteotomized
exposure and osteotomy. The lingual and crestal        segment and then activated to verify its functionality.
mucosa remain untouched.




to be mobilized by turning the drive screw.            each day (Fig 3f). The patient does this with
Then, a 2-mm space is created. It is covered           a special hexagonal screwdriver that has an
by callus during the resting phase until the           elastic, flexible spacer. Figures 3g and 3h
beginning of distraction (Fig 3e). Seven days          show preoperative and postoperative radio-
before distraction, the latency phase begins.          graphic views of the distraction phase.
During this time, the wound closure is                    A 12-week consolidation phase follows
shaped in such a manner that the distractor            the distraction phase. Then, the clinician sur-
enters the mucosa into the oral cavity by only         gically removes the distractor and simultane-
a few millimeters.                                     ously inserts the implant. Figure 3i illustrates
   After 7 days, distraction can begin by turn-        the subsequent prosthetic step.
ing the drive screw 360 degrees clockwise




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  Fig 3f The patient can activate the distractor with   Fig 3g Panoramic radiograph immediately after the operation with the
  the corresponding screwdriver.                        distractor in its original position.




  Fig 3h   Panoramic radiograph immediately after the distraction phase.   Fig 3i Clinical situation 1 month after insertion of
                                                                           crowns.




                     Case 2                                                volume that was gained (compare with Fig
                     An 18-year-old patient was referred to us after       4a). When applying the distractor, it is impor-
                     trauma to the anterior teeth and failed replan-       tant to consider the vector to establish the dis-
                     tation of the maxillary central incisors. From a      traction direction. Especially in the area of
                     general medical point of view, there were no          maxillary anterior teeth, it is important that
                     contraindications for implants. There was not         there is not a strong pull toward the palate.
                     enough bone to do a direct implantation.                 Figure 4f shows the intraoperative situation
                     Figures 4a and 4b show the initial clinical           during removal of the distractor and the hard
                     and radiographic situations with distinct ver-        substance that was gained between the cra-
                     tical and horizontal bone deficiency. It was          nial and caudal fixation points. Subsequently,
                     decided to use a distractor.                          2 Straumann implants were inserted in the
                         Fixation of the distractor, with a buccal         region of the central incisors (Fig 4g). The
                     incision and slight elevation of the mucope-          maxillary right lateral incisor also underwent
                     riosteal flap in the area of the alveolar process     endodontic treatment, since the patient was
                     segment to be mobilized, is shown in Fig 4c.          experiencing some pain in that area. Figure 4h
                     Figure 4d shows the panoramic radiograph              shows the dental radiograph 6 months after
                     immediately after distraction, and Fig 4e             insertion of the implants. The prosthetic pro-
                     shows the patient’s noninflamed mucosa                cedure is pending. Figure 4i shows the interim
                     before removal of the distractor, as well as the      prosthetic situation.




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Fig 4a Initial clinical situation with distinct vertical   Fig 4b Preoperative panoramic radiograph showing a gap in the
and horizontal bone deficiency.                            region of the maxillary central incisors.




Fig 4c Fixation of the distractor and buccal inci-         Fig 4d   Panoramic radiograph immediately after the distraction phase.
sion. The goal is to keep the mucoperiosteal flap as
low as possible.




Fig 4e Noninfected mucosa before removal of the            Fig 4f Intraoperative situation during removal of
distractor.                                                the distractor with a significantly increased amount
                                                           of hard tissue substance.




  g                                                    h                                 i
Fig 4g Insertion of 2 Straumann implants.
Fig 4h Dental film 6 months after insertion of the implants.
Fig 4i Provisional prosthetics for the central incisors.




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                  DISCUSSION                                           implant treatment. Microvascular bone trans-
                                                                       plants (microsurgical vascular suture) have a
                  Improvement of the local soft tissue situation       lower degree of resorption but are very elab-
                  is a positive secondary effect of the callus         orate and can usually be done only with
                  distraction.13,14 The main limitation of the free    reconstructive surgery.
                  bone transplant is the amount of soft tissue            The main advantages of vertical distrac-
                  that is available. The lack of soft tissue is also   tion osteogenesis are the following:
                  the main cause for local complications. Since
                  the free bone transplant does not increase           1. Less resorption
                  the mucosa, the procedure exceeds the limi-          2. No need to harvest a bone transplant, and
                  tations of the tissue where the transplant is           no problems in the area from which the
                  situated, despite extensive mobilization of the         bone is harvested
                  mucoperiosteal flap. Another disadvantage is         3. Low morbidity and infection rate com-
                  that the attached gingiva is moved from the             pared to conventional techniques
                  crestal to the oral area, so that later only         4. Augmentation of soft tissue
                  mobile, substandard mucosa is available for          5. Implantation possible after 3 months
                  the implantation bed.16
                      Advantages of distraction are that it is not        A possible complication of distraction is
                  necessary to harvest autologous bone,15,18           postoperative hypoesthesia of the nervus
                  there is very little resorption, and it has low      mentalis in the mandible, but the hypoesthe-
                  infection and morbidity rates. This tech-            sia usually decreases.22
                  nique’s biggest disadvantage is the monitor-             Since a slight possibility always exists that
                  ing of the bone segment during distraction.19        the anatomic structures could be injured dur-
                      Distraction osteogenesis can be divided          ing a procedure and that some scarring could
                  into 3 phases: latency, distraction, and con-        occur following multiple procedures, these
                  solidation. The latency phase is the time from       considerations could be of importance for the
                  the surgical procedure to the beginning of           esthetically challenging anterior tooth region.23
                  distraction. The distraction phase is when               It is possible to terminate or discontinue
                  the clinician actively distracts, and the con-       distraction at any time. The ideal distraction
                  solidation phase is the time needed for the          speed is 0.25 to 0.5 mm per day; this was
                  bone to completely heal and ossify after dis-        histologically tested with animal experi-
                  traction. Within 4 weeks after the completion        ments.24,25 In addition, Nosaka et al26 point
                  of distraction, new bone forms in the distrac-       out the durability and quality of distracted
                  tion space, and within 3 months, a stable net-       bone as preparation for implantation. Also,
                  work of newly formed bone can be seen.               Periotest measurements of implant mobility
                  From a histologic perspective, Yamamoto et           are within the normal range.27
                  al20 first detected new bone formations along            Few data are available concerning the
                  the collagen fibers. Later, they found a com-        long-term survival rate of implants in the
                  plete bone network.                                  mandible after distraction osteogenesis in
                      The distracted alveolar process segment          partially edentulous patients.
                  is nourished through the respective perios-              Unfortunately, the complication rate of the
                  teum or through the mucosa. Therefore, the           distraction osteogenesis technique is high. In
                  periosteum should be opened as little as             the literature, the total percentage of compli-
                  possible. The vertical distraction procedure         cations ranges from 0%30 to 100%.31 Enislidis
                  offers the possibility of a pedicled trans-          et al 200528 showed that 75.7% of patients
                  plant near the continuous periosteal blood           experienced complications that required addi-
                  supply.                                              tional treatment measures. Most complica-
                      Thus, there should be significantly less         tions in their study were of minor nature; sup-
                  resorption than with a free bone transplant.         plementary corrective augmentation proce-
                  According to Neukam et al,21 the postopera-          dures were needed in 11 of 45 distraction
                  tive resorption rate of a free bone transplant       sites, and four-fifths of complications occurred
                  is close to 100% within 3 years without              during the time between distractor implanta-




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tion and distractor removal. Major complica-                   7. Bloomquist DS, Turvey TA. Bone grafting in dentofa-
tions such as fractures of basal bone were                        cial deformities. In: Bell WH (ed). Modern Practice in
                                                                  Orthognathic and Reconstructive Surgery. Phila-
seen in every fifth patient.28
                                                                  delphia: Saunders, 1992:830-835.
                                                               8. Ilizarov GA. Basic principles of transosseous com-
                                                                  pression and distraction osteosynthesis. Ortop
                                                                  Travmatol Protez 1971;32:7–15.
CONCLUSION                                                     9. McCarthy JG, Schreiber J, Karp N, Thorne CH,
                                                                  Grayson BH. Lengthening of the human mandible
Distraction osteogenesis undermines the                           by gradual distraction. Plast Reconstr Surg 1992;
                                                                  89:1–8.
theory that it is not an uncomplicated proce-
                                                              10. Klein C. Die Knochenverlängerung nach Ilizarov zur
dure although implants can be safely insert-
                                                                  Behandlung der mandibulären Mikrognathie im
ed in distracted areas and long-term survival                     Kindesalter. Fortschr Kiefer Gesichtschir 1994;39:
of loaded implants is satisfactory.                               150–152.
    Since free bone transplantation has such                  11. McCarthy JG, Staffenberg DA, Wood RJ, Cutting CB,
a high total morbidity, researchers looked for                    Grayson BH, Thorne CH. Introduction of an intraoral
alternatives. Distraction is an effective thera-                  bone-lengthening device. Plast Reconstr Surg 1995;
                                                                  96:978–981.
py for preimplant augmentation of the eden-
                                                              12. Wangerin K. Der enorale Zugang bei Ilizarov-
tulous alveolar ridge and an alternative to
                                                                  Kallusdistraktion am Unterkiefer. Dtsch Z Mund
conventional procedures.32 In the future, opti-                   Kiefer Gesichtschir 1995;19:303–307.
mized distraction devices will help surgeons                  13. Block MS, Chang A, Crawford C. Mandibular alveolar
alleviate the patient’s complaints.                               ridge augmentation in the dog using distraction
    Distraction is a promising and relatively                     osteogenesis. J Oral Maxillofac Surg 1996;54:
new augmentation procedure within the dis-                        309–314.

cipline of implant dentistry. Additional results              14. Chin M, Toth BA. Distraction osteogenesis in max-
                                                                  illofacial surgery using internal devices: Review of
from clinical studies are pending.
                                                                  five cases. J Oral Maxillofac Surg 1996;54:45–53.
                                                              15. Hidding J, Lazar F, Zöller JE. The vertical distraction
                                                                  of the alveolar bone. J Craniomaxillofac Surg 1998;
                                                                  26(suppl 1):72–76.
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