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Int. J. Oral Maxillofac. Surg.

2001; 30: 510517


doi:10.1054/ijom.2001.0134, available online at http://www.idealibrary.com on
Clinical paper:
Distraction osteogenesis
Alveolar ridge augmentation by
distraction osteogenesis
A. Rachmiel, S. Srouji, M. Peled: Alveolar ridge augmentation by distraction
osteogenesis. Int. J. Oral Maxillofac. Surg. 2001; 30: 510517. 2001
International Association of Oral and Maxillofacial Surgeons
Abstract. Distraction osteogenesis is an alternative method for reconstructing
atrophic alveolar bone. Fourteen patients underwent vertical alveolar distraction
by the LEAD SYSTEM

-Endosseous Alveolar Distraction System (Stryker


Leibinger, Kalamazoo, MI). An alveolar segmental osteotomy was carried out and
the vertical distraction device was mounted. In patients with an extensive alveolar
defect, two distraction devices were placed in order to better control the vector of
elongation in both bone edges. The distraction was started on the fourth
postoperative day at a rate of 0.8 mm/day for 1016 days, followed by a
consolidation period of 60 days. Vertical distraction osteogenesis (VDO) was
completed successfully in all patients with segment lengths in the range of 8 to
13 mm and with an average of 10.3 mm. Subsequently, the devices were removed
and 23 threaded titanium dental implants were placed for osteointegration. Earlier
mineralization in the vertically distracted area was seen radiographically during the
consolidation period. In a follow up of 620 months after the distraction, 22
implants were successfully osteointegrated while one implant failed due to
improper distracted segment stability. As a result of alveolar distraction, a segment
of mature bone was transported vertically in order to lengthen the crest for better
implant anchorage, either for aesthetic purposes or for functional prosthetic
requirements. The main advantages of VDO are: (1) augmentation of alveolar bone
height with new bone formation and simultaneous expansion of the soft tissues; (2)
no bone harvesting is necessary; (3) the technique has a lower morbidity rate
compared with conventional techniques; (4) it makes the insertion of longer dental
implants feasible.
A. Rachmiel
1,2
, S. Srouji
1
,
M. Peled
1,2
1
Department of Oral and Maxillofacial Surgery,
Rambam Medical Centre;
2
The Bruce Rappaport Faculty of Medicine,
Technion-Israel Institute of Technology, Haifa,
Israel
Key words: distraction osteogenesis; alveolar
ridge augmentation; dental implants; alveolar
bone atrophy.
Accepted for publication 8 May 2001
Published online 3 August 2001
The indications for alveolar ridge
augmentation (ARA) are acquired or
congenital alveolar defects. Common
aetiologies of acquired alveolar bone
loss are postextraction, traumatic avul-
sion of teeth, periodontal disease or after
tumour resections.
The nature of the deciency may
present an obstacle to ideal implant
positioning by compromising aesthetic
and prosthetic needs.
Multiple reconstructive and regener-
ative methods have been applied in order
to augment the alveolar ridge. Current
treatment modalities for alveolar ridge
reconstruction include autogenous bone
grafting
23,31,32
, guided bone regener-
ation (GBR)
4,13
, and use of alloplastic
materials
4,13
. Each of these modalities
has its advantages and disadvantages.
When using an autogenous bone graft,
donor site morbidity is unavoidable
16
and some resorption of the bone graft
occurs
1
. Although the GBR technique
for ARA has been extensively docu-
mented
4,13
, the diiculty in providing
adequate space for the regeneration and
obtaining suicient bone volume is a
known fact. This technique is useful for
limited defects of the alveolar ridge.
Alloplastic materials
4,13
are not suitable
for implant placement. In the case of an
edentulous mandible, a visor osteotomy
8
may be carried out. This technique
however results in poor alveolar ridge
conditions for implantation.
Iiiz:ov demonstrated that gradual
traction on bone after corticotomy
creates stress that can stimulate bone
generation
11,12
; this became an accepted
way of elongating long bones. Distrac-
tion osteogenesis was subsequently
0901-5027/01/060510+08 $35.00/0 2001 International Association of Oral and Maxillofacial Surgeons
applied successfully to cranio-
maxillofacial bones both experimen-
tally
14,19,29
and clinically
18,20,25,28
.
The results of distraction osteogenesis
seen in long enchondral bones and facial
membranous bones suggest that distrac-
tion osteogenesis of the alveolar bone
may be an alternative method for recon-
structing alveolar atrophy with contour
decits. The combination of distraction
osteogenesis with osteointegration can
produce a stable aesthetic reconstruction
of the alveolar bone and attached
mucosa.
Biocx et al.
2,3
described the potential
of distraction osteogenesis for ARA
using animal experiments. CniN &
To1n
5
demonstrated the rst application
of ARA by distraction in humans with
alveolar ridge defects following trau-
matic loss of teeth using a central
intraosseous core device (LEAD

SYSTEM). Recently, G:ccir et al.


6,7
and KiriN et al.
15
demonstrated a
new operative technique for alveolar
ridge augmentation using a distraction
implant.
The purpose of this study is to present
our experience in alveolar ridge aug-
mentation using a central endosseous
distraction device (LEAD

SYSTEM)
followed by implant placement.
Materials and methods
Fourteen patients aged 1855 years with
decient alveolar bone underwent ARA
using the distraction osteogenesis
method. The aetiology of the defects was
traumatic in another six cases, while four
cases were of postextraction after severe
periodontitis, and two cases of alveolar
atrophy due to anodontia (Table 1). The
nature of deciency posed either a struc-
tural or aesthetic obstacle to successful
delivery of a dental prosthesis.
The operation was performed on 12
patients under local anaesthesia and i.v.
sedation and on two patients under gen-
eral anaesthesia. The vertical alveolar
distraction was performed using the
LEAD

SYSTEM (Leibinger

Endos-
seous Alveolar Distraction System).
Two cases, one in the mandible and one
in the maxilla, are presented in Figs 1
and 2.
Surgical technique
After a horizontal incision in the vesti-
bulum, a buccal mucoperiosteal ap
elevation was performed exposing the
lateral cortex, without elevation of the
crestal mucosa. Two vertical osteotomies
were carried out using a reciprocating
saw. A third horizontal osteotomy was
performed apically joining the vertical
component. In this manner an alveolar
segmental osteotomy was achieved. The
segmental osteotomy was carried out
immediately adjacent to neighbouring
teeth in order to accomplish full defect
coverage without damage to periodontal
structure. In the mandible, the vertical
osteotomies should not compromise the
continuity of the mandible or the in-
ferior alveolar nerve. The osteotomy was
carried out at a distance of 5 mm from
the mental nerve. In the maxilla, the
osteotomies should not penetrate the
maxillary sinus or nasal cavity. Before
the mobilization of the transported
segment, a 2 mm hole was drilled
through the crestal mucosa and bone
for placement of the lead screw (thread
distracted rod). When the top of the
crest was knife-edged, after reecting the
crestal mucosa, minimal shaving of the
crest was performed just in order to drill
the hole for the threaded rod. The trans-
ported segment was mobilized using an
osteotome, ideally without reecting the
crestal mucosa. The distraction device
consists of a 2 mm diameter threaded
rod and two small bone plates: a trans-
port plate that was xed by 1.2 mm
xation screws onto the transported
bone, into which the threaded rod was
introduced, and a base plate that was
xed by 1.2 mm xation screws to the
base of alveolar bone (Figs 1G, H, 2B).
Placement of the threaded rod is per-
formed in the middle between the adja-
cent teeth in the bucco-lingual direction
in the place of the future implant. When
rotating the lead screw, the threaded
transport plate travels along it, resulting
in a vertical movement of the bone seg-
ment. Dierent lengths of threaded rods
are available for dierent elevations.
When the space consisted of more than
three single root teeth or two molar
teeth, two distraction devices were used
in order to control the bone elevation in
both edges of the osteotomy (Fig. 1G).
After verication that the device was
functioning properly, the osteotomy seg-
ment was returned as close as possible to
its original position; a 12 mm distance
is acceptable.
The wound was closed primarily by
suturing the periosteum and mucosa
(Fig. 2C). It is important to cover the
Table 1. Decient alveolar bone, primary data of patients
Patient
no.
Age
(years) Diagnosis Location
Vertical
distraction
performed
Follow-up
after
distraction
(month) Complication
1 34 Post extraction Upper canine right side 8 mm 18 None
2 24 Anodontia Mandible molar area right and left 10 mm 16 None
11 mm
3 20 Post trauma Anterior mandible 10 mm 14 None
4 18 Post trauma Anterior maxilla 10 mm 14 None
5 31 Post extraction Upper canine left side 10 mm 20 None
6 43 Post extraction Anterior mandible 9 mm 12 Loss of one implant
7 46 Anodontia Right mandible 12 mm 13 (1) Fracture of base plate
(2) Temporary hypoesthesia
right mental nerve
8 32 Post trauma Anterior mandible 11 mm 12 None
9 55 Post extraction Anterior mandible 10 mm 20 None
10 38 Post trauma Anterior maxilla 9 mm 15 None
11 25 Post trauma Anterior maxilla and right canine area 13 mm 16 None
12 18 Post trauma Anterior mandible 11 mm 13 None
13 39 Post extraction Anterior mandible 9 mm 6 None
14 38 Post extraction Upper canine right side 11 mm 8 None
Alveolar ridge augmentation by distraction osteogenesis 511
512 Rachmiel et al.
osteotomy line with the periosteal layer
in order to maintain the distraction
space needed for bone generation. The
distraction started across the horizontal
osteotomy in a vertical direction on the
fourth postoperative day, by turning the
distraction rod two turns per day for
1016 days, depending on the amount of
bone to be augmented (Table 2). After a
retention period for bone consolidation
of 30 days (at least twice the distraction
period) the threaded rod was removed
by turning the lead screw in the opposite
direction. After an additional 30 days (a
total of 60 days of consolidation), when
the distracted segment was stable the
alveolus was exposed by a crestal in-
cision and the transported plate and base
plate were removed. Twenty-three ti-
tanium cylindrical implants (ScrewVent
Paragon, Sulzer Dental Inc., Carlsbad,
CA), 13 mm in length, and 3.7 mm in
diameter, were then introduced into the
augmented bone (Fig. 2E). Following
distraction, all 14 patients were observed
between 620 months. Radiographs,
panoramic and periapical X-rays were
taken following distraction and after
implant placement. The height of the
bone at the distracted area was measured
vertically along the distracted rod. Press-
ure or mastication on the distracted
rod or onto the elevated mucosa by a
Fig. 1. (A) 24-year-old patient with maxillary hypoplasia and mandibular prognathism. (B) Class III malocclusion. (C) The prole of the patient
after LeFort I maxillary advancement and mandibular setback by sagittal split osteotomy. (D) The postoperative panoramic X-ray demonstrated
alveolar atrophy of the right and left mandible. (E) The right mandibular alveolar atrophy. (F) The left mandibular alveolar atrophy. (G)
Segmental alveolar osteotomy of the right side with two distraction devices. The distraction device is composed from a long threaded distraction
rod and two bone plates: A transport plate that was xed onto the transported bone and the base plate that was xed to the base bone. (H)
Segmental alveolar osteotomy of the left side with one distraction device. (I) The postdistraction alveolus on the left side. (J) Panoramic X-rays
immediately postoperative with the alveolar osteotomies in the right and left sides. (K) The elevated segment in the right and left sides. The
underlying distracted gap is more radioluscent. (L) After removal of the distraction devices and implant placements. The distracted gap was more
radio-opaque.
Alveolar ridge augmentation by distraction osteogenesis 513
Fig. 2. (A) 18-year-old patient after mandibular fracture and
traumatic avulsion of the anterior teeth and alveolar bone. (B)
After the alveolar osteotomy (arrow) and placement of the
distraction device. (C) At the end of the operation, before
distraction. (D) The augmented alveolus after alveolar distrac-
tion. (E) Insertion of two titanium implants. (F) The panoramic
X-ray demonstrates the maxillary alveolar bone loss that does
not permit implant placement. (G) The panoramic X-ray after
the osteotomy and before the lengthening. (H) The augmented
alveolus after lengthening. (I) After removal of the device and
two implant placements.
514 Rachmiel et al.
temporary denture should be avoided
during the distraction period and con-
solidation.
The exposure of the implants was per-
formed 6 months after their insertion,
and the prosthetic rehabilitation began
thereafter.
Results
Fourteen patients underwent vertical
distraction osteogenesis for alveolar pro-
cess augmentation followed by dental
implant placement. The postdistraction
follow-up period was between 620
months. The distraction was evident
clinically and radiographically. Clini-
cally, in all cases vertical elevation of the
transported bone was between 813 mm
with an average of 10.3 mm (Table 1).
The attached mucosa remained at the
top of the crest. It is possible that the
precise vertical elevation of bone is not
the distance measured with the dis-
tracted rod due to some sinking of the
device in the bone resulting from occlu-
sal forces. Radiographically, an earlier
mineralization could be seen during the
consolidation period. At the removal of
the device plates and implant placement
(after 60 days), there was increased
radio-opacity of the distracted area that
indicates the beginning of mineraliz-
ation. Reconstruction of the defects by
the distraction osteogenesis method
allowed enlargement of bone mass for
dental implant placement.
There was no clinical evidence of
infection during the active lengthening
and consolidation period in any of the
patients. In one patient, postoperative
hypoaesthesia of the mental nerve was
noted, which resolved after 2 months
(Table 1).
From the 23 threaded osteointegrated
implants that were introduced, 22
implants achieved osteointegration and
good consolidation. One implant failed
due to inadequate stability of the dis-
tracted bone segment, probably due to
mastication forces during distraction
and after the implant placement. Eleven
implants have been loaded with dental
prostheses.
In one case the device rod penetrated
into the basal bone following a fracture
of the base plate. In this case the plate
was replaced using the same approach.
The primary follow up revealed stability
of the implant that was osteointegrated.
There was no resorption of the superior
aspect of the alveolar ridge. In the
future, a longer follow up should be
made to measure eventual bone
resorption and nal alveolar height
achieved.
Discussion
Reconstruction of the alveolus is chal-
lenging because the deformity involves
deciencies in both the bone and
mucosa. Development of miniature
internal distraction devices has made
alveolar distraction osteogenesis practi-
cal clinically.
An experimental study
21
using a mini-
ature distraction device, demonstrated
successful tooth-borne distraction of the
mandible, resulting in lamellar bone at
the distracted gap. Later, in clinical
demonstrations
22
, a 1 cm widening of
the mandible was achieved using a
tooth-borne distraction device.
Biocx et al.
2,3
described the potential
of distraction osteogenesis for ARA
using animal experiments. On: et al.
24
in
an experimental study in adult dogs
histologically and radiographically dem-
onstrated alveolar ridge augmentation,
the development of new bone in the
distraction area, and the integration of
implants within both the transported
segment and the new bone.
CniN & To1n
5
demonstrated the rst
ARA application in humans after trau-
matic alveolar loss (traumatic avulsion
of teeth).
Currently, vertical distraction osteo-
genesis of alveolar bone can be per-
formed by three distraction systems:
1. Central application of the device
5
(for example: LEAD

SYSTEM,
Leibinger

Endosseous Alveolar
Distraction System)
2. Eccentric application of the device
9
(for example, TRACK distractor by
Martin, Tuttlingen, Germany)
3. Distraction by an implant
6,7
(for
example DIS-SIS distraction implant
and ACE dental implant system,
Brockton, MA).
The former two systems require two
operative stages: rst, the distraction
osteogenesis device placement and
second, a procedure for the removal of
the device and implant placement. The
third system, using a distraction implant
(DIS-SIS distraction implant, SIS Inc.,
Klagenfort, Austria)
6,7
, needs only one
operative step for distractor placement
and implant insertion. The second dis-
traction implant (ACE dental implant
system) needs to be removed and
replaced by an implant. More experience
and long-term follow up is still needed in
the future in order to compare between
the three systems of alveolar distraction.
It is important after placement of the
distraction device to cover the buccal
part of the osteotomy site with perios-
teum in order to maintain the space
needed for bone regeneration. As a
result of alveolar distraction in our
patients, a segment of bone was trans-
ported vertically to reconstruct the
alveolar crest. New bone was regener-
ated in the distraction gap supporting
the transported bone. This is important
in order to achieve better implant
anchorage and aesthetically functional
prosthetic reconstruction.
The main advantage of the vertical
alveolar bone distraction is that there is
an increase in alveolar bone height with
new bone formation beneath the dis-
tracted bone. Distraction osteogenesis
avoids the donor site morbidity associ-
ated with bone grafting and the compli-
cations that accompany the recipient
site. In the case of bone graft augmen-
tation, there is often a need for local ap
advancement to cover the bone and later
a secondary alveoloplasty to create at-
tached mucosa at the crestal area. In
contrast, in vertical distraction osteo-
genesis there is the advantage of simul-
taneous distraction of bone and soft
tissue, while the original pre-operative
attached mucosa remains at the crest.
The crestal bone remains cortical and
mature and therefore expected to resorb
less than if the implant was placed in
grafted bone. Following distraction
there is minimal resorption of bone with
a lower infection rate. The new bone
created by distraction in the maxilla
26
and mandible
10
has been proved to be
stable and predictable. R:cnxiri et al.
26
in a 1-year follow-up experimental
study found only a 7% relapse after
Table 2. Alveolar distraction protocol
Osteotomy
and device
placement
Latency
period
Gradual
distraction
Consolidation
period
(threaded rod
removal
after 30 days)
Implant
placement
(and removal
of the plates)
Exposure of
the implant
and prosthetic
rehabilitation
4 days 0.8 mm/day 60 days After 6 months
1016 days
Alveolar ridge augmentation by distraction osteogenesis 515
40 mm maxillary advancement. In the
mandible
10
, no relapse was noted after
distraction. However, in alveolar distrac-
tion osteogenesis, the vector of lengthen-
ing was vertical and against the occlusal
forces, therefore, longer follow-up
studies should be performed regarding
the stability of the alveolar height and
eventual bone resorption.
It is known that new regenerating
bone gradually becomes mature lamellar
bone
14,27,30
. With mineralization during
the period of retention (consolidation),
the bony trabeculae become thicker with
a mixture of woven and lamellar bone.
Histological studies done in our research
laboratory
27
demonstrated the progres-
sive mineralization of the distracted
membranous bone by comparing the
mineral bone concentrations. It was
demonstrated that at the end of active
gradual distraction the mineralization of
the new bone was 24.3% in comparison
with the control non-distracted bone. At
the end of the retention period, there is
an increase in mineralization to 77.8%,
that continues to increase in the long-
term follow-up period. It is known from
experimental studies that after the reten-
tion period, the new bone is mostly
mature lamellar bone
21,27
. Therefore, in
the present study, at the end of the
retention period (60 days after the dis-
traction) when the bone is mostly mature
lamellar bone, the device plates were
removed and implants inserted. The
implants were placed when the dis-
tracted segment was stable and radio-
opacity of the distracted gap began.
During the period of lengthening and
even in the period of consolidation, the
regenerated bone is not mature enough
and we do not recommend a temporary
denture to overlie the alveolus in order
to prevent relapse in the nal alveolar
height. Pressure or mastication over the
threaded rod or on the elevated segment
must be avoided during the period of
distraction and consolidation of the new
bone. A temporary denture, if needed,
should have only adjacent dental sup-
port, avoiding mucosal pressure on the
distracted area.
A histological study done by Li et al.
17
indicated that cell proliferation of bone-
forming cells during distraction osteo-
genesis is aected by the rate of
distraction. A slow rate of 0.3 mm/day
does not maximally stimulate cell pro-
liferation. A rate of 0.30.7 mm/day
gives an increase in cell proliferation,
and a distraction rate of 0.7 mm/day is
the optimal for cell proliferation and
histological characteristics. Rates of dis-
traction higher than 1.3 mm/day cause
tissue damage such as cyst formation
and necrosis. Therefore, in the present
alveolar distraction study a rate of
0.8 mm/day was applied (two turns of
the threaded rod). If it is possible, it is
preferable to limit the distraction to
0.4 mm twice a day.
During the retention period, the main
rod maintains the elevated segment and
after the implant placement the threaded
implants contribute to maintenance of
the elevated segment together with the
underlying distracted bone. Therefore
threaded cylindrical implants are recom-
mended when the implantation is per-
formed immediately after the distraction
device is removed.
It is important to place the distraction
device according to the correct distrac-
tion vector in order to avoid a labial
deciency of the augmented segment.
The orientation of the distraction rod
should be toward the middle of the adja-
cent teeth in the bucco-lingual direction.
One precaution regarding the LEAD

SYSTEM is the relative insuicient stab-


ility of the device that is important to
keep the vector straight. Another dis-
advantage is the need for a second pro-
cedure for device removal. This can be
avoided by an unremovable distraction
implant
6,7
. However in this case, an
unpredictable vector of distraction due
to improper implant placement cannot
be corrected later.
In the mandible the vertical osteoto-
mies should not compromise the conti-
nuity of the mandible or damage the
inferior alveolar nerve. The osteotomies
were carried out at a distance of 5 mm
from the mental nerve. The method
should not be applied in a very atrophic
mandible, where a complete bone frac-
ture may occur, or in severe posterior
alveolar atrophy of bone where damage
to the alveolar nerve may occur. In order
to prevent a fracture or resorption of
the alveolar transported segment, care
should be taken not to make it too small.
The transported segment should be at
least 5 mm in height for connection with
the plate and screws, while wide enough
to contain within it the threaded rod and
later, the dental implant. For example,
in severe atrophy of the posterior man-
dible if the bone above the inferior
alveolar nerve is less then 6 mm high,
there is insuicient bone to cut into
without damaging the nerve, and dis-
traction in this case should therefore be
avoided.
In our patients, as a result of the
distraction process, the segment of
mature bone was transported vertically
into the alveolar ridge defect in order to
lengthen the crest, both for implant
placement and for either aesthetic or
functional prosthetic reconstruction,
permitting a normal relation between
implants and crowns.
In future, several issues should be
considered:
1. Planning and maintaining the proper
vector of distraction.
2. When to place the implant: at the end
of the retention period, later or even
earlier?
3. Follow up of the alveolar height and
eventual rate of bone resorption.
In conclusion, the internal endosseus
alveolar distraction device is applicable
in acquired and congenital alveolar ridge
defects, resulting in an increase in
alveolar bone height and new bone for-
mation: this allows stable dental implant
insertion in the augmented bone. Dis-
traction osteogenesis provides an oppor-
tunity for simultaneous reconstruction
of the alveolar bone and the overlying
mucosa, avoiding the need for bone graft
augmentation.
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Address:
Dr Adi Rachmiel
103 Yefe Nof
Haifa 34454
Israel
Tel: 972 4 8362013
Fax: 972 4 8428126
E-mail: adi

rach@netvision.net.il
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