Int. J. Oral Maxillofac. Surg. 2007; 36: 700705 doi:10.1016/j.ijom.2007.05.002, available online at http://www.sciencedirect.

com

Clinical Paper Pre-Implant Surgery

Complications and relapse in alveolar distraction osteogenesis in partially dentulous patients

Eppo B. Wolvius, M. Scholtemeijer, M. Weijland, W. C. J. Hop, K. G. H. van der Wal: Complications and relapse in alveolar distraction osteogenesis in partially dentulous patients. Int. J. Oral Maxillofac. Surg. 2007; 36: 700705. # 2007 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons. Abstract. Vertical distraction of the alveolar process is an efcient method for augmentation prior to inserting dental implants. In this study, complications of this procedure and relapse of the transport segment were evaluated in partially dentulous patients. Twenty patients underwent distraction by means of extraosseous distractors. The location of the defects was the anterior mandible (4), posterior mandible (4), anterior maxilla (10) and posterior maxilla (2). Bone height was measured on panoramic radiographs preoperatively, after distraction and after implant placement at the mesial and distal point of the implant(s). Mean alveolar distraction was 6.5 mm at the mesial point (P < 0.001) and 6.1 mm at the distal point (P < 0.001). The mean relapse at the mesial point was 20% and at the distal point 17% (P < 0.05). The intraoperative and postoperative problems encountered were fracture (1) and lingual (4) and palatal (6) displacement of the transport segment. Overall complication rate was 55%. Of all implants placed (n = 63) one was lost. Implant success rate was 98%. Distraction seems to be a suitable treatment for vertically decient alveolar bone, but a relatively high although manageable complication rate must be confronted, including considerable relapse.

Eppo B. Wolvius1,2, M. Scholtemeijer2, M. Weijland1, W. C. J. Hop3, K. G. H. van der Wal2

1 Department of Oral and Maxillofacial Surgery, St. Anna Hospital, Geldrop, The Netherlands; 2Department of Oral and Maxillofacial Surgery, Erasmus MC Rotterdam, The Netherlands; 3Department of Epidemiology and Biostatistics, Erasmus MC Rotterdam, The Netherlands

Key words: alveolar; distraction osteogenesis; implant. Accepted for publication 2 May 2007 Available online 2 July 2007

A common prerequisite for the treatment of patients with complex ridge deformities is the regeneration of sufcient vertical and horizontal alveolar support to facilitate implant placement. Whereas traditional bone grafting utilizes a free bone graft, distraction osteogenesis (DO) is a pedicled graft technique, in which the transport segment is never totally sepa0901-5027/080700 + 06 $30.00/0

rated from its original blood supply. This increases the likelihood that the tissue will remain vital and that resorption is minimized. CHIN & TOTH5 introduced distraction in alveolar reconstruction prior to inserting dental implants. Numerous case reports1,2,5,19 with the rapid development of new devices9,12,17 followed, and authors of recent predominantly retrospec-

tive small series have discussed the potential of this technique in implant dentistry3 5,8,12,13,21,23 . Especially in partially dentulous patients, alveolar DO (ADO) seems to be a promising treatment modality8,12,13,15,21,23. Relapse and long-term results in craniofacial distraction have been reported in several clinical studies, and resulted in

# 2007 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.

Complications and relapse in alveolar distraction osteogenesis

adjustment of the distraction protocol to include overcorrection of 1525%11,18,24. Information on the optimal level of overcorrection is scarce. Various distraction procedures and protocols have been described, but among different groups of patients of varying ages. Comparison of studies is difcult and, as a result, the quantication of overcorrection is almost impossible. In ADO the occurrence of relapse has also been reported2, but only recently have SAULACIC et al.23 and POLO et al.21 determined relapse in extensive series of partially dentulous patients and consequently made suggestions for overcorrection. The purpose of this study was to evaluate intra- and postoperative complications of ADO in partially dentulous patients and to monitor possible shortterm relapse of the distracted transport segment.
Material and methods

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Fig. 1. Three-dimensional computed tomography at initial presentation of a patient with a benign tumour in the anterior region of the mandible demonstrating major loss of alveolar bone.

From January 2001 to October 2005, 20 partially dentulous patients (9 males and 11 females aged 2172 years, mean 36.8 years) underwent vertical alveolar distraction. Inadequate alveolar height was the result of atrophy after tooth extraction and periodontal disease (n = 13), benign tumour resection (n = 2), trauma (n = 4) or oligodontia (n = l). The primary indication for alveolar reconstruction with vertical distraction was to achieve a favourable functional and aesthetic outcome with optimal crown-to-implant ratio, or to achieve sufcient alveolar bone cranial of the mandibular canal. In these cases the insertion of dental implants with a minimal length of 6 mm was not possible. Ten segments were localized in the anterior maxilla (incisor/canine region), two segments in the posterior maxilla (premolar/molar region), four segments in the anterior mandible and four segments in the posterior mandible. In all patients extraosseous (subperiostal) devices (Track Distractor 1.0 mm or Track Distractor 1.5 mm; Gebru der Martin, Tuttlingen, Germany) were used. The mean follow-up was 1.4 years, with a range of 4 months3.5 years.
Surgical procedure

at least two screws (1.5 mm in diameter) and at the basal bone with at least six screws. In all cases the rod of the distractor was positioned somewhat outside the distraction area. The distractor was temporarily removed and the osteotomies were completed. Care was taken to preserve the palatal and lingual periosteum. The distractor was repositioned and tested to identify obstacles in the distraction path. Finally, the transport segment was returned to the most basal position and the mucoperiosteal ap was closed. After a latency period of approximately 1 week following surgery, distraction was started at a daily rate of 0.9 mm (three activations of 0.3 mm). The consolidation period was 2.84 months (range 0.85.5 months). In 18 cases the distractors were removed and implants inserted in one surgical procedure. In two cases implants were placed 2 weeks after removal of distractor. All these secondary procedures were performed with local anaesthesia. In 10 cases after implantation, 12 mm (at most) of

the titanium rough surface of the implants was not fully covered with bone (see Fig. 5). Additional minor bone grafting consisted of covering this cervical area with small bone chips locally harvested via the same ap. No second donor site intra- or extraorally was therefore used. In another ve cases, the alveolar atrophy was horizontal and vertical in such a way that rst an augmentation with bone of the iliac crest had to be carried out to gain enough width of alveolar bone, which could then be distracted in a secondary procedure (Figs. 15: a patient with a benign tumour in the anterior region of the mandible).
Bone height

All patients were evaluated by comparing three consecutive panoramic radiographs made (1) just before the distraction procedure, (2) directly at the end of the distraction phase and (3) directly after implant placement. In order to monitor

All patients were operated under general anaesthesia with nasoendotracheal intubation. After inltration with local anaesthesia a vestibular incision was placed. After subperiosteal dissection and exposure of the buccal surface of the planned osteotomy site, a trapezoid osteotomy was outlined but not completed. The distractors were applied at the transport segment with

Fig. 2. After resection of the benign tumour, including removal of all incisors, severe vertical and horizontal bony atrophy remained.

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preoperatively and the radiograph following the distraction period. Bone height following distraction and implantation in relation to bone height before treatment were expressed as means with a 95% condence interval of the difference (95% CI). Comparison between preoperative and postoperative mean values was done by paired t-test analysis. The correlation between these values and the age of the patients was evaluated by Spearmans analysis.
Results

Fig. 3. After bone grafting with autogenous bone from the iliac crest, alveolar distraction was performed in a second procedure.

Fig. 4. The transport segment was pulled lingually during the distraction period.

possible relapse of the distracted bone segment, bone height was measured according to a modication described by SAULACIC et al.23 The bone height on the most mesial and distal sides of the inserted implant(s) was measured as the distance from the alveolar crest and inferior margin of mandible, or oor of maxillary sinus or nasal cavity, and compared to the height of identical points on orthopanoramic radiographs preoperatively as well as post-dis-

traction. The measurement line was perpendicular to the horizontal line connecting clear anatomic landmarks like coronoid process or infraorbital margin. Each measure was multiplied with the magnication index found by comparing the length of each implant on the radiograph with the real length of the inserted implant. These values were used for identication of the same measuring points on the rst orthopanoramic radiograph

In all 20 patients the distractors were implanted successfully and the distraction procedures were accomplished as planned. The intraoperative and postoperative problems encountered were fracture of the transport segment during the surgical procedure with loss of volume in the consolidation period (n = 1, Fig. 6) and lingual (n = 4, Fig. 4) and palatal (n = 6) displacement of the transport segment, all occurring at the end of the distraction period. Overall complication rate was 55% (11/ 20). Of all implants placed (n = 63), one in the anterior maxilla was lost after 6 weeks due to insufcient primary stability. Implant success rate was 98%. The mean gain in alveolar bone height at the mesial point was 6.5 mm (95% CI: 5.6 7.4 mm; P < 0.001) with a mean relapse of 1.2 mm (95% CI: 0.51.9 mm). The mean gain at the distal point was 6.1 mm (95% CI: 5.27.1 mm; P < 0.001) with a mean relapse of 1.5 mm (95% CI: 0.21.6 mm). The mean relapse at the mesial point was 20% (range 1107%; P < 0.05) and at the distal point 17% (range 2115%; P < 0.05); see Fig. 7. As a result the mean bone augmentation was 5.3 mm at the mesial point and 4.6 mm at the distal point of measurement. No correlation was found between age and relapse (for the mesial point P = 0.12 and for the distal point P = 0.22).
Discussion

Fig. 5. Fortunately, the implants could be positioned according to the guiding stent. Additionally, the implants in the cervical region were covered with locally harvested bone chips.

Alveolar distraction is a natural progression in the evolution of the distraction technique. Although the principles of the DO process are well established in endochondral bone of the skeleton, these have not been claried yet for the craniofacial area including the alveolar process. Most reports have been in the form of clinical observations of a few cases or small series18. The recently published rst series on complications, relapse and long-term stability in distraction procedures in the craniofacial skeleton have resulted in

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Fig. 6. A fracture of the transport segment resulted in severe resorption; at 2 months of consolidation, hardly any osseous volume of the transport segment around the xation screws was left.

improvements of devices, adjustment of clinical protocols and determination of the amount of overcorrection11,18. Some authors claim no occurrence of relapse

even over the long-term22. Comparison of studies remains difcult since patient groups, treatment strategies and protocols vary considerably.

Fig. 7. Percentage relapse of the transport segment at the mesial and distal points of the implant(s) following alveolar distraction in 20 patients. The two most outlying observations in this gure correlate with the patient in which a fracture of the transport segment occurred.

Reconstructing alveolar bone in a patient with a three-dimensional defect, which is often the case, can be difcult. A combination of vertical guided bone regeneration (GBR), conventional onlay grafting and vertical distraction is often mandatory to achieve an optimal functional and aesthetic result with implant-borne prosthetics. In the current study, in ve patients (25%) alveolar distraction was combined with a major conventional grafting procedure carried out before the distraction. In the case of a vertical and horizontal defect, onlay grafting with bone of the iliac crest was the rst step to create sufcient width of bone in order to facilitate alveolar distraction. In 10 cases (50%), the distracted alveolar bone appeared not to be wide enough prior to implant placement. Minor additional onlay grafting consisted of covering the titanium surface of the implant with bone chips easily harvested via the same ap. MAZZO15 analysed NETTO & ALLAIS DE MAURETTE 55 patients undergoing ADO procedures and reported combinations of grafting procedures as well. Additional local augmentation could improve aesthetic outcome, especially in the anterior part of the maxilla15. In several cases the transport segment was overdistracted past the horizontal defect so that grafting for width could be avoided, compensating for occasional inclination of the distractor rod21. In one case the vector of distraction was palatally orientated resulting in the regenerated bone being positioned too far palatally. In order to place the implants in the right position, an additional grafting procedure was necessary. Possibly, the bi-directional extraosseous alveolar distractor is the solution for optimal vector management12. Alternatively, HERFORD & AUDIA10 described several mainly orthodontic techniques for maintenance of the correct vector. The two grafting procedures have been compared in experimental and clinical studies 4,20. In an experimental study, PERRY et al.20 demonstrated that both onlay grafting and vertical distraction are appropriate methods for bone augmentation prior to implant placement. CHIA4 PASCO et al. compared in 21 patients the use of GBR with autogenous bone and epolytetrauoroethylene membrane with the use of ADO. It was reported that both methods may improve the decit of vertically resorbed edentulous ridges, although distraction seems to be more predictable over the long-term. Traditional vertical onlay grafting will implicate high levels of initial bone resorption6. In a group of 14 patients with partially edentulous mandibles who underwent vertical onlay grafting with autogenous bone, CORDARO et al.6

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screw xation and devascularization. The transport segments in this study were generally about 810 mm in vertical measure and at least two teeth in alveolar span. Other complications, such as infection of the distraction chamber, premature consolidation, unfavourable osteogenesis with brous union, occlusal interference of distraction rods, soft-tissue dehiscence, breakage of the distractor and wound dehiscence, have not been noted2,8. In general, the complications demonstrated in ADO for partially edentulous ridges seem to be minor and manageable8,21,23. In contrast, ENISLIDIS et al.7 analysed nine patients with totally edentulous mandibles in which an alveolar distraction technique was performed with extraosseous devices. It was concluded that this technique is hazardous and no more advantageous than traditional grafting. In patients with cleft lip and palate, local soft-tissue scars around the maxilla restrict maxilla advancement and increase the relapse rate. By gradually lengthening the bones and the soft tissues, midface distraction can greatly increase postoperative stability and lower the relapse rate24. The advancement can include an overcorrection to overcome the relapse. Similar relapse and overcorrection for ADO has been thoroughly quantied by SAULACIC et al.23. In an analysis of 17 distractions it was concluded that ADO should be performed with an overcorrection of 20% and an additional 20% of the overcorrection distance, anticipating that resorption could override the result of the overcorrection. POLO et al.21 demonstrated in a series of 14 cases of ADO in the posterior mandible a mean gain in height of 5.12 mm with a mean resorption of 0.88 mm, seen above the upper miniplate. Mean relapse was 26.6%, which is considerable. In the present study, a mean relapse was noted of 1.2 mm (20%) at the mesial point and 1.5 mm (17%) at the distal point. Consequently, an overcorrection of approximately 1520% is recommended. More studies are needed to monitor shortterm and long-term stability of generated tissue with distraction, especially since most alveolar distraction procedures seem to be in the aesthetic zone and clinical outcome has to be predictable. In conclusion, a combination of onlay grafting and alveolar distraction is often needed to achieve appropriate threedimensional reconstruction of atrophic alveolar bone. But ADO is not an uncomplicated procedure, and the occurrence of relapse of the distracted segment seems to necessitate an overcorrection of 1520%. Survival of dental implants inserted into distracted areas has been shown to be satisfactory.
References
1. Alkan A, Bas B, Inal S. Alveolar distraction osteogenesis of bone graft reconstructed mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005: 100: 3942. 2. Cano J, Campo J, Moreno LA, Bascones A. Osteogenic alveolar distraction: a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006: 101: 1128. 3. Chiapasco M, Consolo U, Bianchi A, Ronchi P. Alveolar distraction osteogenesis for the correction of vertically decient edentulous ridges: a multicenter prospective study on humans. Int J Oral Maxillofac Implants 2004: 19: 399407. 4. Chiapasco M, Romeo E, Casentini P, Rimondini L. Alveolar distraction osteogenesis vs. vertical guided bone regeneration for the correction of vertically decient edentulous ridges: a 13-year prospective study on humans. Clin Oral Implants Res 2004: 15: 8295. 5. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices: review of ve cases. J Oral Maxillofac Surg 1996: 54: 4554. 6. Cordaro L, Amade DS, Cordaro M. Clinical results of alveolar ridge augmentation with mandibular block bone grafts in partially edentulous patients prior to implant placement. Clin Oral Implants Res 2002: 13: 103111. 7. Enislidis G, Fock N, Ewers R. Distraction osteogenesis with subperiostal devices in edentulous mandible. Br J Oral Maxillofac Surg 2005: 43: 399403. 8. Enislidis G, Fock N, Millise-Schobel G, Klug C, Wittwer G, Yerit K, Ewers R. Analysis of complications following alveolar distraction osteogenesis and implant placement in the partially edentulous mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005: 100: 2530. 9. Gaggl A, Schultes G, Karcher H. Vertical alveolar ridge distraction with prosthetic treatable distractors: a clinical investigation. Int J Oral Maxillofac Implants 2000: 15: 701710. 10. Herford AS, Audia F. Maintaining vector control during alveolar distraction osteogenesis: a technical note. Int J Oral Maxillofac Implants 2004: 19: 758762. 11. Hierl T, Klisch M, Kloppel R, Hemprich A. Distraction osteogenesis in the treatment of severe midfacial hypoplasia. Mund Kiefer Gesichtschir 2003: 7: 713. 12. Iizuka T, Hallermann W, Seto I, Smolka W, Smolka K, Bosshardt DD. Bi-directional distraction osteogenesis of the alveolar bone using the extraosseous device. Clin Oral Implants Res 2005: 16: 700707. 13. Jensen OT, Cockrell R, Kuhike L, Reed C. Anterior maxillary alveolar distraction osteogenesis. A prospective 5year clinical study. Int J Oral Maxillofac Implants 2002: 17: 5268.

noted a mean resorption of 42%. Based on these results and clinical observations, the two techniques seem to be complementary. Distraction is the technique for a vertical decit whereas augmentation or GBR is indicated for a horizontal defect. In addition, ADO will result in the gain of soft tissue without alteration of the vestibular depth. This could optimize the aesthetic situation around the prosthetics. This has been successfully demonstrated by ALKAN et al.1 performing ADO in a grafted mandible and by NOCINI et al.19 showing correction of mandibular height in a case with a post-trauma anterior mandibular bone deciency. It remains to be seen whether the new distractors for horizontal widening of the alveolar ridges will denitively be implemented in the augmentation procedures. The rst clinical reports seem to be promising14. Undoubtedly, like all distraction operations, ADO is time consuming for the patients as well as for the surgeons. The additional hospital costs including general anaesthesia and the cost of the distractor make this an expensive procedure. This must be discussed with patients upon rst consultation, particularly given the costs of the nal prosthodontic treatment. Although a study on the cost efciency of ADO versus conventional grafting will probably result in a negative outcome for the former technique, the two techniques have disparate indications and outcomes as stated above. Complications in distraction of the craniofacial skeleton are numerous. Most reported problems are device related and vary from distractor instability with improper vector control to fracture of the distractor15,18. In ADO similar complications with deviation of correct vector have been demonstrated as in the current series2,8,15,16,20,22. Fortunately, in most cases a slight vector deviation will not compromise implant placement, even in the aesthetic zone of the anterior maxilla. In one case, lingual tilting of the transport segment (Fig. 4) occurred but the implants could be positioned according to the guide stent. At the labial side of the implants, part of the titanium rough surface had to be covered with locally harvested bone chips (Fig. 5). Fracture of the transported or basal bone may cause more severe problems. Resorption of the transport segment may occur and result in a negative outcome, as in one case of the current study (Fig. 6). Obviously, due to lower osseous volume in single-tooth transport segments, a higher complication rate is to be expected. The smaller the segment, the more likely it is that resorption will occur, due most likely to complicated

Complications and relapse in alveolar distraction osteogenesis

14. Laster Z, Rachmiel A, Jensen OT. Alveolar width distraction osteogenesis for early implant placement. J Oral Maxillofac Surg 2005: 63: 17241730. 15. Mazzonetto R, Allais de Maurette M. Radiographic evaluation of alveolar distraction osteogenesis: analysis of 60 cases. J Oral Maxillofac Surg 2005: 63: 17081711. 16. Mazzonetto R, Allais M, Maurette E, Moreira RWF. A retrospective study of the potential complications during alveolar distraction osteogenesis in 55 patients. Int J Oral Maxillofac Surg 2007: 36: 610. 17. McAllister BS, Gaffaney TE. Distraction osteogenesis for vertical bone augmentation prior to oral implant reconstruction. Periodontol 2000 2003: 33: 5466. 18. Mod MM, Manson PN, Robertson BC, Tufaro AP, Elias JJ, VanderKolk CA. Craniofacial distraction osteogenesis: a review of 3278 cases. Plast Reconstr Surg 2001: 108: 11031114. Nocini FP, Albanese M, Prato EB, DAgastino. Vertical distraction osteogenesis of the mandible applied to an iliac crest graft: report of a case. Clin Oral Implants Res 2004: 15: 366370. Perry M, Hodges N, Hallmon DW, Rees T, Opperman LA. Distraction osteogenesis versus autogeneous onlay grafting. Part I. Outcome of implant integration. Int J Oral Maxillofac Implants 2005: 20: 695702. Polo WC, Cury PR, Sendyk WR, Gromatzky A. Posterior mandibular alveolar distraction osteogenesis utilizing an extraosseous distractor: a prospective study. J Periodontol 2005: 76: 1463 1468. Rachmiel A, Aizenbud D, Peled M. Long-term results in maxillary deciency using intraoral devices. Int J Oral Maxillofac Surg 2005: 34: 473479.

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n23. Saulacic N, Somoza-Martin M, Ga dara-Vila P, Garcia-Garcia A. Relapse in alveolar distraction osteogenesis: an indication for overcorrection. J Oral Maxillofac Surg 2005: 63: 978 981. 24. Suzuki EY, Motohashi N, Ohyama K. Longitudinal dento-skeletal changes in UCLP patients following maxillary distraction osteogenesis using RED system. J Med Dent Sci 2004: 51: 2733. Address: E.B. Wolvius, Department of Oral and Maxillofacial Surgery Erasmus MC Rotterdam PO box 2040 3000 CA Rotterdam The Netherlands Tel: +31 10 463 39 55 Fax: +31 10 463 30 98 E-mail: e.wolvius@erasmusmc.nl

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