Int. J. Oral Maxillofac. Surg.

2012; 41: 168170

doi:10.1016/j.ijom.2011.08.003, available online at http://www.sciencedirect.com

Technical Note
Dental Implants

3D vector control during

alveolar ridge augmentation
using distraction osteogenesis
and temporary anchorage
devices: a new technique

D. Aizenbud1, H. Hazan-Molina1,
M. Cohen1, A. Rachmiel2
1
Orthodontic and Craniofacial Department,
School of Graduate Dentistry, Rambam
Health Care Campus and Bruce Rappaport
Faculty of Medicine, Technion Israel
Institute of Technology, Haifa, Israel; 2Oral
and Maxillofacial Surgery Department,
Rambam Health Care Campus and Bruce
Rappaport Faculty of Medicine, Technion
Israel Institute of Technology, Haifa, Israel

D. Aizenbud, H. Hazan-Molina, M. Cohen, A. Rachmiel: 3D vector control during

alveolar ridge augmentation using distraction osteogenesis and temporary anchorage
devices: a new technique. Int. J. Oral Maxillofac. Surg. 2012; 41: 168170. # 2011
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
Abstract. This report describes a combined orthodontic surgical technique involving
vertical alveolar distraction using temporary anchorage devices (TADs) in cases of
massive alveolar ridge bone and teeth loss. A combined surgical orthodontic
protocol included presurgical orthodontic preparation and a preimplantation
surgical augmentation stage for insertion of a vertical distractor. During the active
vertical alveolar distraction process TADs were inserted. Intraoral orthodontic
elastics were attached to the main orthodontic archwire exerting multidirectional
forces to control the vertical distraction vector. After 3 months of vector controlling
and active bone moulding, the TADs were removed. Anterior alveolar ridge
augmentation using distraction osteogenesis was achieved. The application of
TADs for better anterior segment curvature enabled dental implant insertion, better
positioning and restoration. A combined surgical orthodontic management protocol
involving vertical alveolar distraction osteogenesis for augmentation purposes is an
efficient treatment method to improve alveolar ridge volume for the preimplantation
stage.

During the alveolar distraction process,

three dimensional (3D) vector control is
a crucial factor in determining the planned
movement and in maintaining precise evaluation of the desired distraction direction2,3. Owing to the curved architecture
of the maxillary and mandibular alveolar
0901-5027/020168 + 03 $36.00/0

ridge, especially along the intercanine

arch span, the distractor is originally angulated appropriately, but the accurate guidance of the vectors direction is limited.
Consequently alveolar ridge augmentation
during distraction most often results in a
straight and flat alveolar ridge structure

Accepted for publication 19 August 2011

Available online 5 October 2011

rather than a curved one. The delicate

distracted bone is also exposed to the
moulding forces exerted by the surrounding soft tissue matrix. In this way the
transported bone segment is forcefully
pushed inward (in a palatal or lingual
direction) during regular and normal func-

# 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

3D vector control during alveolar ridge augmentation using distraction osteogenesis and temporary anchorage devices
tion of the buccinator mechanism. It is
important to identify the direction of the
newly regenerated bone early enough to
avoid compromising the alveolar ridge
augmentation results.
Temporary anchorage devices (TADs)
are fixed temporarily to the bone to
enhance orthodontic anchorage and are
removed after use. Their advantages, in
addition to their size, include minimal
anatomic limitations, minor surgery insertion, increased patient comfort, immediate
loading, and low cost1,5,6. As an anchorage
device, this type of appliance may be
inserted into a regenerated segment
enabling the application of orthodontic
forces to control the distraction vector,
thus moulding its required form for future
dental restoration.
In this article, the authors present a new
technique for 3D vector control during
vertical alveolar ridge augmentation using
distraction osteogenesis and TADs, for
better anterior ridge curvature form.

Fig. 2. Intraoral frontal view of vertical distraction osteogenesis process of the transported alveolar ridge segment resulting in
desired bone height augmentation.

After a latency period of 5 days, a

vertical distraction of the transported segment begins at a rate of 0.5 mm per day by
turning the device twice a day until the
desired bone height is achieved (Fig. 2).
During the active vertical alveolar distraction process, orthodontic implants (TADs)
are inserted into the transported segment
according to the desired vector orientation
(Fig. 3A). Intraoral orthodontic elastics

Materials and methods

Initially, preliminary orthodontic treatment is carried out to level and align the
maxillary and mandibular dental arches
until both arches are coordinated
(Fig. 1). The preimplantation surgical
alveolar bone augmentation stage includes
vertical distraction of the residual basal
bone using an intraoral distractor (KLS
Martin distractor, Tuttlington, Germany).
The anterior maxillary or mandibular area
is anaesthetized with 2% lidocaine and
1:100,000 epinephrine. A vestibular incision is made in the area of distraction. The
incision plane maintains the vascularization of the soft tissues and consequently
the bone segment to be distracted. A trapezoid osteotomy is performed using an
oscillating microsaw and the distractors
are attached by means of 1.5 mm micro
screws. The surgical incision is sutured to
cover the distractor and the exposed alveolar bone completely. Postoperatively,
500 mg of amoxicillin is prescribed 3
times a day for 7 days.

Fig. 1. Intraoral frontal view after a preliminary phase of orthodontic treatment including
levelling and alignment of the maxillary and
mandibular dental arches.

169

Fig. 4. Postoperative intraoral frontal view of

implant supported prosthesis.

are then attached from the TADs to bent

loops or prefabricated crimpable hooks on
the main orthodontic archwire. These are
banded/attached according to the preplanned desired vector for the 3D distraction process controls. The patient
continues to wear the elastics after the
active distraction period for an 8-week
consolidation period. Later, the vertical
distraction devices are removed under
local anaesthesia. Vector controlling and
active bone moulding using the TADs and
intraoral elastics continues for 810 weeks
until the desired curvature of the transported alveolar segment is achieved for
ideal implant positioning (Fig. 3B).
Finally the TADs are removed and dental
implants can be inserted. Good aesthetics,
functioning and occlusal relationships can
be achieved (Fig. 4).
Discussion

Fig. 3. Orthodontic implants (TADs) inserted

into the transported segment during the active
vertical alveolar distraction process. Vector
controlling and active bone moulding using
intraoral orthodontic elastics attached from
the TADs to the loops on the main orthodontic
archwire. (A) During vertical alveolar distraction process with the vertical distractor still in
place Fig. 3 will appear in black and white in
print and in colour on the web. Based on this,
the respective figure caption has been updated.
Please check, and correct if necessary.(red
circles). (B) Moulding process with intraoral
elastics and TADS continues after the removal
of the distractors until the desired curvature of
the transported alveolar segment is achieved
for ideal implant positioning. (For interpretation of the references to colour in this figure
legend, the reader is referred to the web version of the article.)

Atrophic maxillary bony ridge with profound deficiency, in the vertical and sagittal dimensions, may be presented in cases
with post-traumatic loss of teeth.
The vertical deficient alveolar ridge
can, in some cases, be rehabilitated by
means of implant-supported prosthesis,
but the positioning of dental implants
without any surgical augmentation might
result in placement of implants of a
reduced length which should be rehabilitated by extremely elongated crowns. The
sagittal deficient alveolar ridge dictates
dental implant inclination that may be
inadequate to satisfy the fundamental biomechanical and aesthetic requirements7.
For these reasons, a combined surgical
orthodontic treatment protocol is presented.
Distraction osteogenesis has become a
popular surgical modality mainly in cases
of trauma and correction of craniomaxillofacial deformities. It has many advantages: it is a relatively safe, effective, and a
minimally invasive procedure that can be
performed at any age with a low complication rate. Alveolar ridge distraction
osteogenesis is one of the available techniques for vertical and transversal restora-

170

Aizenbud et al.

tion as the origin of the formed bone is the

basal bone. Since the generated bone is flat
and has no curvature it needs to be
moulded by efficient 3D vector control,
for the shape of a proper, opposing suitable arch, enabling the application of an
implant supported prosthesis.
This article presents a combined
method for controlling the architecture
of the newly restored alveolar bone with
the use of TADs and intraoral orthodontic
elastics. Different techniques have been
described for vector control4,8, but in the
present system, preplanned alveolar ridge
restoration is accurately achieved by balancing its position against the soft tissue
pull by using TADs in addition to orthodontic brackets. The TADs and the orthodontic brackets function as a stable
anchoring device during the distraction
process, especially during the retention
period after the removal of the distractors
which heavily support the regenerated
bone. This eliminates the dependence on
teeth as an anchorage unit as HERFORD &
AUDIA4 suggested and allows the use of
fewer anchoring units than in the methods
described in the literature.
Since the distraction process involves a
device that needs a precise vector, the
direction of bone regeneration can be
altered during the distraction process by
pressure from the oral musculature and
pull from the thick palatal tissue. Consequently, the new alveolar ridge can be
reconstructed, but in a far from ideal position that would not allow optimal placement of the implants with respect to the
anatomic, functional, and aesthetic outcomes. With the addition of intraoral elastics connected to the TADs and the
brackets, the distracted alveolar process
is moulded. The forward traction forces
exerted on the regenerated anterior segment opposite the posterior parts, enable
its movement to the designated position
(Fig. 3) resulting in an improved anterior
segment curvature suitable for the accurate preplanned position of the implant
(Fig. 4). In this system, the direction of
the forces exerted by the elastics can be
easily modified during the distraction and

the retention periods. This allows a multidirectional force control of the vertical
distraction vector in the three dimensions
of space, whilst opposing the soft tissue
pull. Bone generation is accompanied by a
simultaneous expansion of the surrounding soft tissue envelope (i.e. gingiva,
nerves, and vessels), which contributes
to the stability of the reconstruction, lessening the risk of relapse10. This technique
is expensive and demands more treatment
time owing to the need for constant recalls
and adjustments during the distraction
process, compared with the bone graft
procedure, for example.
Relapse is considered the second most
common complication of distraction surgeries, following insufficient bone formation according to SAULACIC et al.9, who
studied the complication rate in alveolar
distraction osteogenesis. Less common
complications are bleeding, paresthesia,
haematoma, infection, wound dehiscence
and problems related to the device such as
backward rotation, micro bone screw loosening, and fracture of screws9. A slight
pain when turning the screw of the distractor is quite common.
In conclusion, the presented technique
of 3D vector control during vertical alveolar distraction osteogenesis for augmentation purposes is an efficient treatment
method to improve alveolar ridge volume
and architectural form as a preimplantation stage.

2.

3.

4.

5.
6.

7.

8.

9.

Funding

None.
Competing interests

None declared.
Ethical approval

Not required.
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Address:
Dror Aizenbud
Orthodontic and Craniofacial Department
Rambam Health Care Campus
P.O. Box 9602
Haifa 31096
Israel
Tel: +972 4 8542265; Fax: +972 4 8339889;
Mobile: +972 54 4327256
E-mail: aizenbud@ortho.co.il