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.

862 VOLUME 38 • NUMBER 10 • NOVEMBER/DECEMBER 2007
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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.
REFERENCES 16. Kunkel M, Wahlmann U, Reichert TE, Wagner W.
Vertical distraction of the alveolar process. Z
1. Nyström E, Kahnberg KE, Gunne J. Bone grafts and Zahnärztl Implantol 1999;15:71–77.
Branemark implants in the treatment of the severe- 17. Gaggl A, Rainer H. Vertical alveolar distraction using
ly resorbed maxilla: A 2-year longitudinal study. Int J a new intraoral distractor [abstract]. J Cranio-
Oral Maxillofac Implants 1993;8:45–53. maxillofac Surg 1998;26(suppl 1):55.
2. Tripplet RG, Schow SR. Autologous bone grafts and 18. Zechner W, Bernhard T, Zauza K, Celar A, Watzek G.
endosseous implants: Complementary techniques. Multidimensional osteodistraction for correction of
J Oral Maxillofac Surg 1996;54:486–494. implant malposition in edentulous segments. Clin
3. Caplanis N, Sygurdson TJ, Rohrer MD, Wikesjo UME. Oral Implants Res 2001;12:531–538.
Effect of allogenic, freeze-dried, demineralized 19. Raghoebar GM, Heydenrijk K, Vissink A. Vertical dis-
bone matrix on guided bone regeneration in traction of the severely resorbed mandible: The
supraalveolar peri-implants defects in dogs. Int J Groningen distraction device. Int J Oral Maxillofac
Oral Maxillofac Implants 1997;12:634–642. Implants 2000;29:416–420.
4. Schliephake H, Neukam FW, Wichmann M, 20. Yamamoto H, Sawaki Y, Ohbuko H, Ueda M.
Hausamen JE. Langzeitergebnisse osteointegrierter Maxillary advancement by distraction osteogenesis
Schraubenimplantate in Kombination mit using osseointegated implants. J Craniomaxillofac
Osteoplastiken. Z Zahnärztl Implantol 1997;13: Surg 1997;25:186–191.
73–78.
21. Neukam FW, Scheller H, Günay H. Experimentelle
5. Laurie SWS, Kaban LB, Mulliken JB, Murray JE. und klinische Untersuchungen zur Auflagerung-
Donor-site morbidity after harvesting rib and iliac sosteoplastik in Kombination mit enossalen
bone. Plast Reconstr Surg 1984;73:933–938. Implantaten. Z Zahnärztl Implantol 1989;5:235–239.
6. Kestel M, Ewers R, Lambrecht JT. Sensibilitäts- 22. Gaggl A, Schultes G, Regauer S, Kärcher H. Healing
störung des Nervus cutaneus femoris lateralis nach process following alveolar ridge distraction in
Beckenspanentnahme. Fortschr Kiefer Gesichtschir sheep. Oral Surg Oral Med Oral Pathol Oral Radiol
1985;30:69–70. Endod 2000;90:420–429.

VOLUME 38 • NUMBER 10 • NOVEMBER/DECEMBER 2007 865
Q U I N T E S S E N C E I N T E R N AT I O N A L
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23. El Askary AS. Esthetic considerations in anterior sin- 29. Chiapasco M, Consolo U, Bianchi A, Ronchi P.
gle-tooth replacement. Implant Dent 1999;8:61–67. Alveolar distraction osteogenesis for the correction
24. Wiedemann M. Morphologische Grundlagen der of vertically deficient edentulous ridges: A multi-
Kallusdistraktion. Zentralbl Chir 1994;119:587–593. center prospective study on humans. Int J Oral
Maxillofac Implants 2004;19:399–407.
25. Gaggl A, Schultes G, Kärcher H. Distraktions-
implantate. Ein neues augmentatives Konzept mit 30. McAllister B. Histologic and radiographic evidence
prothetisch versorgbaren Distraktoren. Dtsch of vertical ridge augmentation utilizing distraction
Zahnärztl Z 2001;55:57–62. osteogenesis. 10 consecutively placed distractors. J
Periodontol 2001;72:1767–1779.
26. Nosaka Y, Tsunokuma M, Hayasi H, et al. Placement
of osseointegrated implants in distraction osteoge- 31. Garcia-Garcia A. Minor complications arising in
nesis at the consolidation period. In: Diner P. alveolar distraction osteogenesis. J Oral Maxillofac
International Proceedings, 2nd International Surg 2002;60:496–501.
Congress on Cranial and Facial Bone Distraction 32. Simion M, Jovanovic SA, Tinti C, Benfenati SP. Long-
Processes. Paris: Monduzzi Editorial, 1999. term evaluation of osseointegrated implants insert-
27. Isidor F. Mobility assessment with the Periotest sys- ed at the time or after vertical ridge augmentation.
tem in relation to histological findings of oral A retrospective study on 123 implants with 1–5
implants. Int J Oral Maxillofac Implant 1998;13: year follow-up. Clin Oral Implants Res 2001;12:
377–383. 35–45.

28. Enislidis G, Fock N, Millesi-Schobel G, et al. Analysis
of complications following alveolar distraction
osteogenesis and implant placement in the partial-
ly edentulous mandible. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2005; 100:25–30.

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