Results and complications of alveolar distraction osteogenesis to

enhance vertical bone height

Tayfun Gnbay, DDS, PhD,a Banu zveri Koyuncu, DDS, PhD,b M. Cemal Akay, DDS, PhD,b
Aylin Sipahi, DDS, PhD,b and Ugur Tekin, DDS, PhD,c Bornova, Turkey
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, FACULTY OF DENTISTRY, EGE UNIVERSITY

Objective. The aim of this retrospective study was to analyze the outcome and complications of alveolar distraction
osteogenesis for the correction of vertically deficient ridges by using intraosseous and extraosseous distractors.
Study design. Seven patients with severely atrophic alveolar crests were treated by distraction osteogenesis in 5
alveolar ridge deficiencies by intraosseous distractors and in 2 alveolar ridge deficiencies by extraosseous distractors.
The bone deficiencies were secondary to atrophy after periodontal disease, tooth extraction, or trauma. Three months
after consolidation of the distracted segments, implants were placed in the distracted areas. The average follow-up
period after prosthetic loading was 50 months.
Results. The mean alveolar height achieved was 7.8 mm (range, 4-9 mm). The intraoperative and postoperative
problems encountered were lack of device activation (n 1), lingual displacement of the distracted segment (n 1),
paresthesia of the lower lip (n 4), and dehiscence and plate exposure (n 2). Most of these complications were
considered to be minor complications and were solved without any problems.
Conclusion. It was concluded that alveolar distraction osteogenesis seems to be an effective technique to treat vertical
alveolar ridge deficiencies, but adequate treatment planning is necessary for success. The complications related to this
technique can be solved with simple treatments. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e7-e13)

Dental rehabilitation of partially or totally edentulous
patients with dental implants has become popular in the
last decades with long-term results. Success rates for
dental implants averages 90%.1-5 However, vertical
defect of the alveolar ridge may render the use of dental
implants difficult or impossible owing to an insufficient
bone volume. Various methods for alveolar ridge re-
construction exist, such as autogenous bone grafting,6-8
guided bone regeneration, and use of alloplastic mate-
rials.9,10 Alveolar distraction osteogenesis (ADO) was
introduced by Chin and Toth in 199611 and has been
applied as an alternative technique to the other surgical
techniques.12 The method is widely used for increasing
alveolar bone where rehabilitation with dental implants
is required,13-15 and it makes the insertion of longer
implants possible.16 Compared with the conventional
techniques of bone grafting and guided bone regener-
Supported by the Branch Directorate of Scientific Research Projects,
University of Ege.
a
Professor, Department of Oral and Maxillofacial Surgery, Faculty of
Dentistry, Ege University, Bornova, Turkey.
b
Senior assistant, Department of Oral and Maxillofacial Surgery,
Faculty of Dentistry, Ege University, Bornova, Turkey.
c
Associate Professor, Department of Oral and Maxillofacial Surgery,
Faculty of Dentistry, Ege University, Bornova, Turkey.
Received for publication Sep 28, 2007; returned for revision Nov 27,
2007; accepted for publication Dec 14, 2007.
1079-2104/$ - see front matter
2008 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2007.12.026
ation, ADO offers the advantages of decreased bone
resorption, lower rate of infection and no donor site
morbidity13,16,17 and gain of soft tissue.13,15,18 The dis-
advantages include difficulty in controlling the seg-
ments, lack of patient cooperation, the need for more
office visits, and the cost of the device.19-21
In the present study, our experiences, including com-
plications, with the Lead and Modus systems are pre-
sented, and advantages and disadvantages of these sys-
tems are discussed.
MATERIAL AND METHODS
Patients
Seven systemically healthy patients, 6 women and 1
man, aged between 24 and 64 years, who presented
with vertical alveolar ridge mandibular defects, were
treated with ADO by 2 types of distractor devices:
intraosseous (Lead System; Leibinger, Freiburg, Ger-
many) and extraosseous (Modus Ars 1.5; Medartis,
Basel, Switzerland) between February 2003 and June
2005. All of the patients signed an informed consent
form. The type of distractor was chosen considering the
location and length of the edentulous area. Two of the
defects were in the premolar aspect of the mandible, 2
were in the anterior mandible, 1 in the anterior maxilla,
1 in the molar aspect of the mandible, and 1 in the
premolar-molar mandible region. The deficiencies were
caused by periodontal disease or atrophy after tooth
extraction (n 4), trauma (n 2), or hypodontia (n

e7

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e8 Gnbay et al.
Table I. Features of the patients and type and number of distractors
Case no. Age Gender Distraction zone
1 38 M Mandibula premolar
2 26 F Mandibula premolar
3 30 F Maxilla anterior
4 64 F Mandibula anterior
5 24 F Mandibula premolar-molar
6 53 F Mandibula molar
7 48 F Mandibula anterior
l). One rod was placed in 3 patients and 2 rods in 1
patient with wide defects who were treated with in-
traosseous distractors (Lead System) (Table I). When 2
rods were used, they were positioned as parallel as
possible. Routine radiographic documentation of the
treated patients was obtained with panoramic and in-
traoral radiographs taken preoperatively, immediately
after the application of the distractor, at the end of the
distraction procedure, at the time of implant placement,
at the time of prosthetic rehabilitation, and annually
thereafter. Clinical examinations concerning the dental
implants included periimplantitis, implant mobility,
and gingival condition. Two cases, one in the maxilla
and one in the mandible, are presented in Figs. 1 and 2.
Surgical technique
All the operations were performed under local anes-
thesia. A crestal incision was made along the alveolar
ridge. A buccal mucoperiosteal flap elevation was per-
formed exposing the lateral cortex, maintaining the
attachment of the lingual mucoperiosteum to the trans-
port segment. The lateral vertical bone cuts were made
in an angulated manner to achieve a trapezoid-shaped
bone segment. Then a horizontal osteotomy was per-
formed, leaving a minimum 4 mm of bone preserved
for the maintenance of sufficient blood circulation in
the later alveolar bone segment. Before the mobiliza-
tion of the transported segment, a 2 mm hole was
drilled through the crestal mucosa and bone for place-
ment of the lead screw (thread-distracted rod). Mobili-
zation of the bone segment was achieved using fine
chisels. The transport plate was fixed by fixation screws
onto the transported bone, into which the threaded rod
was introduced, and a base plate was fixed by fixation
screws to the base of alveolar bone. After testing that
the device was functioning properly, the osteotomy
segment was returned as close as possible to its original
position. The mucoperiosteal flap was closed primarily
with 3.0 Vicryl sutures (Johnson & Johnson Intl., Som-
erville, NJ).
For extraosseous devices, the surgical procedure was
identical. All patients received 600 mg clindamycin per
day, continuing for 7 days, and nonsteroidal analgesics.
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May 2008
Type of distractor Etiologic factor No. of distractors
Lead System Gun shot 1
Lead System Hypodontia 1
Lead System Traffic accident 2
Modus Edentulous 1
Lead System Alveolar resorption 1
Lead System Alveolar resorption 1
Modus Edentulous 1
Postoperative instructions for the patients included soft
diet and oral hygiene with 0.2% chlorohexidine mouth-
rinse. Sutures were removed 7 days after surgery. The
distraction protocol involved a latency period of 7 days.
After this time period, activation of distraction devices
was started at a rate of 0.8 mm twice daily by Lead
System and 1 mm twice daily by Modus. After the
augmentation of desired transport was obtained, the
device was left in place for approximately 6-8 weeks to
stabilize the segment.
The prosthetic restoration of implants was performed
after 3-4 months of osseointegration. A total of 14
endoosseous implants were placed. During clinical fol-
low-up, distractor mobility, situation of distracted seg-
ment, and function of nervus alveolaris inferior were
examined once a week. Clinical and radiologic fol-
low-up periods were 6-56 months.
RESULTS
Vertical distraction osteogenesis was performed in 7
patients in the study, 5 using Lead System and 2 using
Modus. The gained distance was evident clinically and
radiographically. The mean vertical formation achieved
in the patients was 7.8 mm (Table II).
All of the patients tolerated the operations well ex-
cept one. That patient felt severe pain during the dis-
traction period. Therefore we reduced the distraction
rate (0.25 mm), which relieved the discomfort.
There was no clinical evidence of infection during
the distraction period and consolidation period in any of
the patients. Incorrect vector of the distracted segment
occurred in 1 patient, but sufficient bone was gained. In
that patient the displaced segment was repositioned
with orthodontic device. In 4 patients, postoperative
paresthesias of the mental nerve was noted which re-
solved after 8 weeks with vitamin B treatment. Fracture
of a fixation screw occured in 1 case. Dehiscence and
plate exposure were observed in 1 case but did not
affect the functional or esthetic results. We recom-
mended daily rinsing of the area with chlorohexidine
mouthrinse for the treatment. The complications and
the treatments are summarized in Table III.
These minor complications were treated and did not
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Volume 105, Number 5 Gnbay et al. e9

Fig. 1. A, Panoramic radiograph of 30-year-old patient after mandibular fracture and traumatic avulsion of the anterior teeth and
alveolar bone. B, Placement of the alveolar distractor during surgery. C, Panoramic radiograph after lengthening of the alveolar
bone. D, After removal of the device and 4 implant placements. E, Panoramic radiograph 3.5 years after final prosthetic
rehabilitation.

have an influence on the outcome of distraction. Dental
implants were successfully inserted. We observed im-
mature bone in 1 case during the removal of the dis-
tractor device. Therefore, we delayed insertion of the
endoosseous implants for 2 months.
In case 1, gunshot defect was repaired by distraction
osteogenesis, but mucosal scar tissues prevented acti-
vation of distractor and required vertical augmentation
with sandwich osteotomy technique. Implant insertion
was not possible in case 4 because of the patients
financial problems. Complete denture was applied to
that patient.
In the radiologic follow-up, no severe resorption in
the periimplant region was observed. Implants were
loaded prosthetically in 7 patients with a mean fol-
low-up after loading of 50 months (range 6-56 months).
None of the implants were lost.
DISCUSSION
Vertical alveolar distraction osteogenesis method
demonstrates many advantages in treating vertical al-
veolar bone defects compared with conventional meth-
ods from the aspect of bone quality, bone quantity,
donor site morbidity, and decreased bone resorption.
The main advantage of the vertical alveolar bone dis-
traction is that there is an increase in alveolar bone

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 OOOOE
e10 Gnbay et al. May 2008

Fig. 2. A, Panoramic radiograph of 48-year-old patient with severely resorbed mandible. B, Intraoral photograph showing
mandibular atrophy. C, Segmental alveolar osteotomy of the anterior region with extraosseous alveolar distractor. D, Postdis-
traction panoramic radiograph showed lengthening of the alveolar bone. E, Panoramic radiograph 1.5 years after final prosthetic
rehabilitation.

height with new bone formation beneath the distracted
bone. Furthermore, simultaneous lengthening of the
surrounding soft tissues is achieved by histiogen-
esis.19,22,23
New bone regeneration was performed in the distrac-
tion gap supporting the transported bone. This is im-
portant to achieve better implant anchorage and esthet-
ically functional prosthetic reconstruction.
Distraction osteogenesis can be achieved by in-
traosseous24,25 or extraosseous devices.26 Distraction
osteogenesis with intraoral extraosseous distractors of a
single tooth space may in fact be more difficult to
perform, owing to the limited space available for os-
teotomies and the dimensions of the distraction device.
In the present study, we used the Lead System as an
intraosseous distractor. It is especially used at the pos-

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OOOOE
Volume 105, Number 5
Table II. Gained bone amount, transport width, num-
ber of implants, and type of prosthesis in the distracted
area
Case Distraction Transport No. of
no. (mm) wdth implants Type of prosthesis
1 4 23 Precision attachment
2 9 13 3 Fixed partial denture
3 8 42 4 Fixed partial denture
4 9 34 Complete denture
5 9 25 3 Fixed partial denture
6 8 29 2 Fixed partial denture
7 8 15 2 Ball attachment
terior regions of the mandible with limited spaces when
opposing teeth were available. When compared with
extraosseous devices, whose main components are
placed on the surface of the bone, intraosseous devices
have several advantages, including the capability of
distracting very small bone segments, not requiring any
pins or plates to hold the distractor in place, and being
a better tolerated device by the patients because of their
small dimensions.17,27 However, we can no longer
agree with the last claim, because we observed that our
patients tolerated both types of the distractors.
Some authors do not recommend a temporary den-
ture to overlie the alveolus to prevent relapse in the
final alveolar height during the period of lengthening
and even in the period of consolidation, because regen-
erated bone is not mature enough.16 In our cases, we
also did not advise temporary dentures. In one case, we
noted immature bone in the mandible during the re-
moval of the distractor device, and we postponed in-
sertion of the endoosseous implants for 2 months.
Clinical and experimental reports have shown that
ADO is effective for treating severe forms of alveolar
ridge atrophy12,13,18,23,28 and is a reliable technique for the
correction of vertically deficient edentulous ridges,26
but some intra- and postoperative complications can
occur.19,29-31 The complications have been reported as
fracture of the mandible, fracture of the transport segment,
difficulties in finishing the osteotomy on the lingual side,
excessive length of the threaded rod, incorrect direction of
distraction, perforation of the mucosa by the transport
segment, suture dehiscence, and bone formation defects.
Fracture or resorption of the alveolar transported
segment may occur as a complication; care should be
taken not to make it too small, but at least 5 mm in
height.15,16 Another reason for the resorption of the
transported segment is inadequate spongiosa bone, so
horizontal osteotomy must be widened as much as
possible.32 However, it must be kept in mind that if the
remaining bone becomes too thin, the risk of mandib-
ular fracture and nerve damage will also increase.16
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Gnbay et al. e11
Alveolar distraction should be avoided in a very atro-
phic mandible, where a complete bone fracture may
occur. Fracture of the mandible is the most severe
complication encountered.26,29,30 In the present study,
patients whose mandibular bone was at least 9-10 mm
vertically were for these reasons preferred. Fracture of
the transport segment and mandible during surgery was
not observed.
Difficulties were encountered in completing the os-
teotomy on the lingual side, which we had to access
from the labial vestibular side. To do this, some authors
have constructed fine chisels from cement spatulas
which were carefully introduced from the vestibular
side, checking their exit from the lingual side with a
finger to avoid damage to the lingual mucoperiosteum
or the floor of the mouth, but the ultrasonic osteotome
has proven to be much more comfortable, without the
risk of damage to the vascular plexa of the floor of the
mouth.19
A common problem with the Lead System is the diffi-
culty of controlling the direction of the device to keep the
vector straight.16,19,24 Inappropriate direction of distrac-
tion may be caused by any of several factors, including
resistance of the soft tissue on the lingual/palatal side of
the muscles and intact periosteum.19 The distractor will
tend to lean to the lingual side, requiring postoperative
repositioning. Careful preoperative planning is essential to
ensure good vectorization.33 Repositioning of a displaced
transport segment is generally performed using orthodon-
tic appliance arch wires.16-20,34 In 1 patient the displaced
segment was repositioned with orthodontic device. It has
been reported that extraosseous distractors maintained
much more stabilization at basal and transport segments
than intraosseous distractors.35 In the present study, we
did not notice malposition of the transported segments at
extraosseous distractors. We think that malposition and
stabilization problems that were seen in intraosseous dis-
tractor were related to lack of stabilization in that type of
distractor. When the transport segment is relatively long
(more than about 2 cm), it may be difficult to achieve
accurately controlled osteogenesis using a single distrac-
tor. The use of 2 distractors, one at each end of the
transport segment, resolves this problem.19,20,24,36 For this
reason, we applied 2 distractors in a wide maxillary defect
in case 3.
Temporary paresthesias showed spontaneous resolu-
tion within 6-8 weeks with conservative treatment, sim-
ilar to other studies,31,37 in our 4 patients. The use of an
ultrasonic osteotome might decrease the risk of nerve
damage during osteotomy preparation.31
The activation period of the distraction device is
usually pain-free38; however, we noted tension-related
pain in 1 patient because of more than 1 cm of alveolar
distraction. The pain disappeared when the rate of

e12 Gnbay et al.
Table III. Minor and major complications in alveolar distraction osteogenesis with necessary treatments
Case no. Major complications Minor complications
1 Lack of device activation Paresthesia of the nerve
2 Incorrect vector of the transport segment
Dehiscence and plate exposure
Paresthesia of the nerve
3
4 Dehiscence and plate exposure
Severe pain
5 Paresthesia of the nerve
6
Immature bone at time of removal of distractor
Paresthesia of the nerve
7 Fracture of screw
distraction was reduced to 0.25 mm/24 h. It is sug-
gested to increase the frequency of elevation without
changing the daily rate.37 Parallel or convergent lateral
osteotomies during activation may result, with discom-
fort, friction, and possible compromise of the final
outcome. Applying lateral osteotomies divergent to one
another during surgery is recommended.26 We made
trapezoidal osteotomies in operations for facilitation of
the transport segment movement. Saulacic et al.31 men-
tioned that the varying amount of distraction performed
in patients reporting pain in their clinical study indi-
cated that the occurrence might be subjective. We agree
with these authors, because the statement of our patient
about pain may be doubtful.
Soft tissue dehiscence was the most common minor
complication (37.8% of distraction sites) with 6.7% of
these becoming infected in a recent study. One of the
causes for this may well be the distraction rate of 0.9 mm
per day.30 Dehiscence and plate exposure were found in 2
of the present cases, but did not affect the functional or
esthetic results. We recommended daily rinsing of the area
with chlorohexidine mouthrinse for treatment.
In other published studies, the prevalence of complica-
tions that compromised the final outcome is 2.7% to
20%.18,26,30,38 It was concluded in a clinical study that
ADO is an effective technique to treat vertical alveolar
ridge deficiencies.29 Most complications related to surgery
can be avoided with adequate treatment planning.26 In
other clinical studies the authors reported that most of the
minor complications could be readily resolved by the use
of appropriate procedures, but very close follow-up is
required.19,20,29 Vertical alveolar distraction osteogenesis
is not an uncomplicated procedure; however, long-term
survival of dental implants inserted into distracted areas is
satisfactory.30 On the other hand, Enislidis et al.39 re-
ported that the use of subperiosteal devices for vertical
augmentation of edentulous mandibles is hazardous and
offers no advantage over other surgical methods and that
all of the patients had severe complications. Fukuda et
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May 2008
Treatment
Local
Repositioned with orthodontic devices
Local
Local
Local
Reduction of distraction rate
Local
Delay of insertion of implants by 2 months
Local
None
al.40 also stated that vertical distraction osteogenesis for
implant placement appeared to have serious risks and
complications in reconstructed bone. We have not ob-
served serious complications, such as fracture of the man-
dible, fracture of the transport segment, infection, or
breakage of the distraction device in our study. Among the
major complications, in 1 patient mucosal scar tissues
prevented activation of alveolar distractor. We recom-
mend using ADO technique in atrophic crests including
scar tissues carefully.
In conclusion, ADO is an effective technique to treat
vertical alveolar ridge deficiencies. The intraosseous
distractors can be used for distraction of small bone
segments because of their small dimensions, but diffi-
culty of vector control is the disadvantage of the Lead
System. Modus maintained much more stabilization at
basal and transport segments than intraosseous distrac-
tors. Alveolar distraction osteogenesis seems to be
valid for simultaneous reconstruction of the alveolar
bone but adequate treatment plannig is necessary for
the success. Complications of this technique can be
solved with simple treatments.
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Reprint requests:
Dr. Banu zveri Koyuncu
Department of Oral and Maxillofacial Surgery
Ege University
Bornova
Turkey
banuozverikoyuncu@yahoo.com