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The International Journal of Periodontics & Restorative Dentistry



32 1

Distraction Osteogenesis to Ach ieveM andibu lar Vertical Bone

Regeneration: A Case Report

Giacomo Urbani. MD. DDS'/Giorgio Lombardo. MD. DDS"/

Enrico Santi. DDS"'/Ugo Consolo. MD, DDS""

In ihis case report a surgical technique for vertical ridge augmeritaficn is presenled-

Jiie procedure, performed in a 30-year-oid woman with an atrophied aiveoiar ridge

in the anterior portion of ttie mandibie, is based on ttie biologic concept of osteoge-

nesis distraction previously introduced in orthopedic and moxillofocial surgery. After

elevation of a fuil-fhickness fiap a horizontoi osteotomy was performed 7 to 8 mm

from the top of tt\e ridge. Two verficol osteotomies were prepared with drills of

increasing diameter (2.2.8. and 3 25 mm ), topping wos performed for the first 5 to 6

mm . and two distractor base plugs were placed at the base of the osteotomies wrth

a reposifioning toal. An intraossecus distraction implant was then inserted and 2

inward vertical cuts were made in the bone to allow proper distraction to takeplace. C orrect functioning of the device wos checked by distrooting the bone frag-

ment I mm using the axiai distraction screw. A latency distraction hea ting screw was

inserted in each of the distraction implants and the area was left to heal for 5 days.

Once primary healing hod occurred, the distraction of the newly formed bone callus

was activated each day for 10 days (I mm per day) At the end of the distroction

periodo final distraction screw was left in piace onda final healing screw was insert-

ed. During this time there were no complications and the potient on no occasion

complained of discomfort The distractor device was removed 30 days iater ieaving

tfie Dase piugs in place. One mon th later a verticoi augm entation of 7 mm had

been achieved; the base piugs were removed. 3 intraosseous implants w ere insert-

ed, and a biopsy of the newly formed tissue was obtained Histologie evaiuation of

the biopsy specimen showed woven bone formation approximately 75 days afterthe initiai procedure. (Int J Periodoniics Restorative De ni 1999; 19:321-331.)

"Ch aim ion .De pa rlme nt of Periodontics.Veiono Unrversity Verona, Itoly.

"Ass istant Professor Dep artm ent of PeriodOFitics.Verono University, Verono.

Italy.

"Pr ivat e Praclice, Verona, Italy: an d Formerly, Research Fellow, Depa rtment

of Periodontics. New York University New York.

"C ho irm an , Depo rtmenf of Oral Surgery Mo den a University. Mod ena , Itoly.

Reprint requests: Dr Giacomo Urtxani.Via Michelangelo IZ 37100\ferona,

Italy,

Distraction osteogenesis was first

described in 1905 by C odivilia ' toincreose the lengti^ of the femur,

il izorov ond coworkers^-^ de-

scribed the bioiogic bosis for

heo l ing ond o surg ico i d is -

t roct ion d evic e. A number of

successtui cose results were sub-

sequently presented in the ortho-

pe dic literoture.^-^ In 1973 Snyder

et al^ used a surgicoi de vice for

the osseous distroction of a dog

mandib ie. Since then only o few

outhors have used this t e c h -

nique in the mandible."^^ Since

1990 distraction osteogenesis

has bee n described in the max-

illofocial surgicai reseorch iitera-

ture using human ond onimoi

subjects.'-28 McCorthy et oH^

reported 4 coses of uniiaterolmand ibu lo r hypop las io tha t

were treoted using a miniatur-

ized Hoffman device. Different

dev ices we re subsequen t l y

described by other authors.^^o

in 199ó,Chin on dTo th^' used o n

introorol device o n 5 potients. In

one of these cases, o traumati-

cally indu ced locolized otrophy

ot the a iveo ia r crest was

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322

repaired with a special device, in

a d og study in 1998, Block et al^^

obtained a mean vert icai dis-

traction of 10 mm. By the tenth

treatment week bone f i i i wascontirm ed in the distraction ga p,

Twc impiants were pia ce d in the

ridge, one in the distracted bone

and the other in the nondis-

trac ted oiveoius, One aim of that

s tudy wos to eva iuo te the

degree of csseointegrat ion cf

the impiants pio ce d in the previ-

ousiy distracted bon e,

One requisite for success in

imp iant dentistry is the presence

of an adequate recipient site.

Gu ided b one regeneration (GBR)

techn iques w i th au to iogous

grafts, sinus lift procedures, and

alveolar nerve t ransposi t ions

have been used where the eden-

tulous ridge has been severeiy

resorbed. Expanded palytetraflu-

oroethyiene (e-PTFE) membranes

either alone or witn aiiopiastio

materiais, allcgrafts. and autala-

gous bone grafts have also be en

empioyed, intraorai sites that are

used far auta iogous graf t ing

include the retromoiar area, the

mental symphysis, an d the maxil-

lary tuberosity. These procedu res

may be leng thy and requ i rebone régénérat ion before im-

ptants ca n be pia ce d. Aithough

they present few sequelae in the

anterior sextants, there are more

compiloations in the lateroposte-

rior areas. At present, vertical

g u i d e d P o n e a u g m e n t a t i o n

through guided tissue regenera-

t ion fa i ls to of fer h igh iy pre-

dictable resuits.

The purpose of this case re-

port was to dem onstrate tha t dis-

traction osteogenesis inseiected

oases may be a valid o iternative

to verticai GBR procedures.

Case

A 30-year-oid w om an presented

to the Depar tment o f Per io -

dontics of Verana University, Her

ohief compiaint concerned the

ioss of her mandlbuior tee th from

the ieft iaterai incisor ta the right

canine (Fig l ) .The teetn had

been iost in a car aooident. The

edentuious ridge was severeiy

atrophied. The defect exfended

iingually sa that at its base the

aiveoius was ap ica i to the soft tis-

sue floor of fhe mouth. On pre-

sentation, tne patient was wear-

ing a precisian removabie parfiai

d e n t u r e . A t t a ch m e n t s w e r e

iooated in complete-coverage

restarations aver tne left second

premoiar and fhe right canine.

The remainder of fne m andibular

dentition was restared w ith a fixed

partiai denture (Fig 2), Foiiowing a

comprenensive evaiua tion, a ver-

t ica i r idge augmentat ion and

impiant therapy were discussedwith the patient,The verticai ridge

augmentat ion was advised tc

optimize the crown-to-implant

ratio. Tne use of GBR was ruled

out as an op t ion fo r r idge

augmentat ion because of fhe

iarge volume at fhe defeot and

the knife edge of the residual

alveolar ridge . Distraotion asteo-

genesis using a new intraosseaus

d is t rac t ing dev ice (A iveo ia r

Distractor, ACE Surgicoi Supply)

was onosen as an a lternative.

Technique

A iocai anesthetic (iidocaine 2%,

1 ; 100,000 epinephrine) was infii-

trated Puc cai an d iinguai ta the

surgicai site. A crestal incision was

used, A fuil-thiokness muoope-

riosteai f lap (buccal oniy) was

eievated, exposing fhe aiveoiar

defeot. The Iinguai tla p w as left in

p iace tc p rov ide a constan t

blo od supply throu gh th e perios-

teum. The height of the norrow

a lveo la r r idge po r t ian was

redu ced an d shorp an d irregular

edges were rem oved w ith round

surgical burs tc cbtain a mini-

mum width af 5 mm. Using ah

OMS 5000 osoiiiating microsaw

(Nouva g) a nd asteo tomes, a

horizcnfai 1,0- tc 1,5-mm-wide

osteotomy was piaced on the

buo oai a spect of the alveolus 7

fa 8.5 mm inferior to the crest.

The osteotomy was extend ed to

the barder c f the b an e loss area

(Fig 3), with the saw penetrating

to the Perder af the lingual plate .

Vert ical osteotomies wereprepared fa receive the distrac-

tion devices.The sites were devel-

oped using 3 driiis af increasing

diam eter (2.0,2.8, an d 3,25 mm ),

Tne upper 5 mm of tne asteo-

tomies were ta p p e d far insertion

offne disfraction impiants (Fig 4).

Disfracfor base plugs were in-

serted through bo th crestal open -

ings and piac ed at fhe baftom of

The internation al Journ al of Periodontics & Restorat ive Dentistry



323

Fig 1 Severely resorbed alveolar ridge in the mandityularright quadrant.

Fig 2 Panaramic radiograph shows the extent of the olveolofdefect. A removable prosthesis with precision attachments is

used at this t ime by the patient.

Short, 3.5-mm

threaded bone lap

Fig 3 Horizontal asfeotomy is performed on the ridge. Two

verHcai osteotomies, which are needed for the insertion of Hiedistractor device, are prepared with an incremental drilling

sequence (2.0,2.8.3.25 mm).

Fig ä Distroctor site osteotomies are tapped for the first 5 to6 mm

Volume 19. Number 4.1999



324

Dislractor base plug

Fig 5 Once the Oase plug has been positioned at the base

of the distracfot site, an axial distroctoris

inserted.

Fig ó Distractor placement sequence.

Fig 7 Two oblique osteotomies are peifoimed to facilitatethe distraction of the bone fragment. The movement of ttiebone to be distracted is evaiuated by turning the oxiai dis-troctor screw in the body of the aiyeolar distractor. The bone is

then repositioned by remo^/ing the axiai distractor screw, on da latency distractor healing screw is inserted.

Fig 8 Panoramic radiograph shows the distactor deyioe Inplace and the bone fragment.

the sites with the oici of a reposi-

tioning tool. On ce the base plugs

were found to be properly posi-

tione d, the repositioning tool was

unthreaded and removed, A 5-

mm- lang a lveo la r d is t roo t ion

implant was then inserted using a

standord impiant mount at 20

rpm (Fig 5), With the base plug

and the distraotion implant in

p iace. 2 vert ioo i osteotomies

were made mesialiy and distolly

to release the bony segment,

These inoisions ex tended from the

orest of the ridge to the end of

the horizontal bone cut and to

the iinguoi border. A b on e chisel

was used to fracfure through th e

The Internotionoi Journal of Periodontics & Restorotive Dentistry



325

Final a rslractionliealing screw

Final dislraclionscrew left in place:linal healing screw inserted

Fig 9 Roentgenogroph shows the degree of augmentationat ttie end of the distraction procedure. Nate that one a xialdistractor is not properly seated in the base plug-

Fig ¡0 Final healing screws aie inserted.

linguol plate and free the seg-

ment of bone. To verify the co m -

pleteness of the surgical site

prepa ration the stage 2 axial dis-

traction screw was inserted into

the body o f the d is t ract ionimplant so that 0.5 mm of the

screw extended above ttie hex-

agonal heod of the implant (Fig

6),To test the c om plete mobility of

ifie bone segment, the axial dis-

traction screw was turned to aliow

ttie bone to move 1 mm verfioaily.

Having determined th at the

bone segment had been com-

pletely treed from the interfer-ence of all bon y margins, the dis-

tra cte d segment wds restored to

its original position by removing

the s tag e 2 ax ia i d is t ract ion

screws. Then the bony segment

was allowe d to retum to its origi-

nal position. A cove r screw was

seated over the distraction im-

plant (Fig 7), The labial flap was

reposit ioned using resorbable

sutures (Vicryi . Johnson &

Johnson/Ethicon). The heods of

the cover screws were leff ex-

posed. A ponoramic rodiograph

showed the distractor device in

place and the bone fragmentdetached from the mandibuiar

body (Fig 8). Antibiotics were pre-

scribed for 2 weeks (Au gme ntin

[SmithKline Beecham) 1 g. twice

a day).The pa tient was oiso pro-

vided with an analgesic to be

used on an as-nee ded basis.

Over the next 5 days no treat-

ment was undertaken to allow

initial healing. On the fifth day thedistraction process was begun.

The cover screw was removed.

The stag e 2 oxiai distra ct ion

screw was inserted untii it came

into con tac t with the base plug:

the screw was then ro tated 2 full

turns (one tull turn corresponding

to 0.5 mm of vertica l distraction)

with a screwdriver. Vertical dis-

t ract ion oí the newiy fo rmed

bony callus was set at a rate of

1.0 mm per day (2 screw turns).

Distraction was begun with

the initial stage 2 axial distrac-

tion screw and was followed by

the p lacem ent of additional dis-trac tion screws. Each distraction

screw was able to extend the

bony segment a total ot 2 mm.

The screws, on average, were

chan ged every 2 ddys. A period

of 10 days was neede d to rea ch

the proper vertical augmenta-

tion (Fig 9). At the e nd of the dis-

traction prooed ure the lost axial

d ist ract ion screw wos ie f t inplace. The distract ion implant

was covered with the finai heal-

ing screw (Fig 10).

The hea i ing per iod pro-

ceeded without complicdtions.

The patient reported no pain or

discomfort o nd tolerated the pro-

ced ure well.The site was allowed

to heal tor an additional 30 days

before the alveolar distraction

Volume 19. Number 4.1999



32Ó

Fig 11 Significant degree of vertical ougm entation is

obtdined.

Fig 12 Approximately 75 days after initial surgery a 7-mm ver-

tical augmentationis

defected upon elevation of afull-thick-

ness Hap

dev ice was removed.The patientwos given a local anesthetic an do fuii-thickness mucoperiosteoi

flap was elevated. The removaiprocedure vt/as performed withthe same tools thot were used toinsert the device, but in reverseorder.

in the description of the dis-traction procedure provided bythe m onufacturer of the device,implants ore imm ediateiy ploo edin the site where the distroctian

device hod bee n removed. In thepresent cose, however, becauseof the lingual position of the dis-troctor hoies immediate impiontpiocement vi/os not deem ed fea-sibie. Therefore, removoi of thebase plugs wos deferred until th etime of implant placement, Theflop was repositioned on d suturedin o c onven tiona l manner. Figure

11 cieariy shows the ciinico i gain

in height ochieved on compie-tion of the distraction process.

A surgical flap was ago in ele-

vated 30 doys loter, A verticoiougmentation of 7 mm could beseen and recorde d (Fig 12). Thebose piugs were surrounded byfibrous tissue ond couid be eos-ily rem oved . A bon e biopsy vi/astai<en from the middle of the dis-trocte d bone in a buccolingualdirection.Two 3.75 mm x 15 mmand one 3.25 mm x 13 mm

Osseotite implonts C3i) wereplaced in the edentuious site (Fig13). A fourth impiont, whose posi-t ion was determ ined by a pros-thetic stent, cauid not be stabi-iized because of its proximity tothe distol verticai osteotomy

The biopsied t issue speci-me n wos tixed in 4% buffered for-ma i i n so lu t i o n , d e o o l c i f i e d ,

treated with hemotoxylin-eosin

stain, and prepared for micro-scopic an d polarized iight evol-uations, iHistalogic evaiuation

reveoled the presence of imma-ture bone with a layer oi soft tis-sue (probably part of the peri-osteum) in the most bucca lportion of the biopsy There wosno evidenoe of an inflammatoryceil infiitrate (Fig 14), At higherm agnification, wove n bon e wasfound to be present. The bonehad on eor iy t rabecu la r ap-

pearance and was surroundedby o network of imma ture bone.Bone deposition a nd osteoblastrecruitment were aiso de tec ted(Figs 15 ond ló ).

The internotional Journal ot Periodontics & Restorative Dentistry



327

Fig )3 Three intraosseous implants ore placed in the d istract-

ed ridge.

Fig 14 Wedge Diopsy specimen shows (tie traDecular orga-

nization of immature bone. (Original magnification x 25 :hematoxylin-eosin stain.)

f ig / 5 At higt^er magniticaticn woven öone formation is

detected- Osteablast recruitment is also present witti newbone depositian. (Original magnification x 103; tiemataxytin-eosin stain.)

Fig 16 Immature öony structure similar to t t̂ at stiown in Fig 1 5

IS detected under pclarized ligt)t microscopy. (Original magni-tication X 250.;

Volume 19, Number 4,1999



32 8

Discussion

McCarthy et al'^ and Takato et

a l ^ ' f irst described distraction

osteogenesis in maxi l io facia isurgery. These outhors presented

techniques for the surgical cor-

rection of faciai maltormatians

using extroorol distraction devices

stabilized with tronscutaneous

pins. External distractors are

wideiy used in orthopedic sur-

gery but are unacceptable for

use in the facial areo becouse of

scar formation, internal fixation

devices represent a better soiu-

tion when the procedure is per-

forrTied in the ora l environ-

ment.'^-^°"2' This is especially true

when treating segmentai osseous

defects.

Distraction asteogenesis is a

possible aiternative to GBR tech-

niques when used for verticolaug mentation of alveolar ridges.

Large disfraction devices can-

not be used for this purpose

because the bone volume to be

d is t racted when an a iveo ia r

r idge augmentat ion is needed

for im plant pla ce m en t is usuaiiy

very small—never greater fhan

10 mm in height.

To overco me this problem, anew. exceptionally small aivealar

distractor (ACE Surgicai Suppiy) is

used to pe r fo rm d is t roc t ion

osteogenesis prior to implont

p lacement. This device presents

2 ma in advantages: (1 ) smaii

segments of bone are verticaiiy

distraoted in a relativeiy short

period of t ime: and (2 ) the dis-

tractor works inside the alveolar

ridge, thus eliminating th e ne ed

for externai retaining pins, screws,

or plates in the basal bon e or the

bone to b e distracted. Moreover,

the vertical site prepa ration usedfor insert ion of the distractor

device may be used for place-

menf of fhe implant.

The facf that this intraosseous

device is so well tolerate d repre-

sents a further adv an tag e co m -

pared to other, larger types of

disfractors. On no occasion dur-

ing the treatment period did the

patient com plain of pain or dis-

com fort, reporting oniy a sensa-

fion of "tension" similar to that

expe rienced during orthodontic

movement.

Three problems were e n -

cou ntered , however, at the time

of surgery First, during placem ent

of the base piug in one distraction

site a slight ratation was inadver-tently produced, and when the

axiai distractor was used it was

pushed out of the base piug. This

did not appear to interfere with

praper distraction. The s econd

problem was found during verti-

cai distraction, when strong resis-

tan ce was de tec ted while rotat-

ing the axiai disfracfion screw

close to the midline. This wasooused by contoc t betwee n the

original mandibuiar bone waii

an d the aiveolor bon e fragment.

With a more flared angu iation of

the releasing osteotomies, the

con toct between parts probably

wouid have been reduced as the

bone segment moved upward.

These problems were obviously

related to our lack of expe rience

The Internotion ci Jo urnol of Periodontics & Restorot ive Dentistry



330

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