Prothetic Rehabilitation of Edentulous Ridges Following Alveolar Distraction Osteogenesis. Clinical...

Prosthetic Rehabilitation of EdentulousRidges Following Alveolar DistractionOsteogenesis: Clinical Report ofThree CasesGulfem Ergun, DDS, PhD1*Isil Cekic Nagas, DDS, PhD2

Dervis Yilmaz, DDS, PhD3

Mustafa Ozturk, DDS, PhD3

Patients with complete edentulism who have insufficient bone for endosseous dental

implant treatment present a challenge for dental practitioners. Distraction osteogenesis of

the edentulous alveolar ridges is a process for augmentation of atrophic alveolar bone

before dental implant placement. This clinical report describes the use of distraction

osteogenesis and rehabilitation of patients with a fixed or removable implant-supported

prosthesis to treat mandibular defects. Two female patients with segmental alveolar atrophy

at the posterior regions of mandible and one female patient with defect at the anterior

region of mandible were treated using distraction devices. However, lingual tipping of the

distraction vector occurred during the distraction phase in patient 1. The morphology of the

alveolar bone was also analyzed in relation to the planned implant position. After a

consolidation period of 12 weeks on average, radiologic observation suggested that there

was sufficient bone formation for implant installation. In all patients, implant-supported fixed

or removable prosthetic oral rehabilitation was successfully performed, and the clinical and

radiologic findings were satisfactory. After 4 years of follow-up, no functional or esthetic

difficulties with the implants and restorations were noted. These case reports suggest that

although alveolar distraction osteogenesis seems to be an effective technique for

augmenting atrophic alveolar bone for creating bone and soft tissue, complications may

occur after surgical procedures.

Key Words: dental implants, alveolar distraction osteogenesis, implant-supportedprosthesis

INTRODUCTION

After tooth loss caused by any

variety of reasons, alveolar

ridge bone height and width

deficiencies limit the use of

endosseous dental implants.

To reconstruct a full-thickness alveolar de-

1 Department of Prosthodontics, Faculty of Dentistry,Gazi University, Ankara, Turkey.2 School of Dental Technology, Hacettepe University,Ankara, Turkey.3 Department of Oral and Maxillofacial Surgery, Facultyof Dentistry, Gazi University, Ankara, Turkey.* Corresponding author, e-mail: [email protected]: 10.1563/AAID-JOI-D-10-00004

CASE REPORT

Journal of Oral Implantology 183

fect, autogenous onlay bone grafts tradition-

ally have been performed.1 However, autog-

enous bone graft has the risk of donor-site

problems with the harvesting of the bone

graft and graft resorption.2,3 Guided bone

regeneration has also been presented as a

reliable solution for correcting atrophic

ridges,4 but this technique may result in

unpredictable bone formation or infection

from membrane exposure.5 To overcome the

problems associated with these techniques,

distraction osteogenesis has evolved as a

promising procedure for alveolar ridge aug-

mentation before implant placement.1

Distraction osteogenesis was originally

created for orthopedic purposes to increase

the length of long bones and was later

applied to the maxillofacial region to correct

severe malformations.4,6 The technique relies

on stretching the bones to achieve length-

ening, to generate new bone, and to correct

deformities in height and width.2,7 This

process also aims to bring the bone to the

exact position needed for subsequent

prosthodontic treatment. This is particularly

important for cases in which an implant-

supported fixed prosthetic denture is planned

and oral implants need to be precisely

installed into the desired position.7

The purpose of this clinical report is to

present the clinical experience in treating

defects of edentulous ridges by means of

intraoral vertical distraction osteogenesis

followed by placement of endosseous im-

plants in the distracted areas.

CASE REPORTS

This clinical report included three female

patients (mean age of 55 years) with alveolar

defects caused by periodontal disease or

resulting from traumatic tooth loss and

subsequent atrophy of the alveolar ridge

(Figures 1a and b, 2a and b, 3a and b).

Seventy-year-old patient 1 was referred to

our clinic with a complaint of loose and ill-

fitting complete mandibular dentures. Pa-

tient 2, a 55-year-old with a removable

partial denture in the mandible and a

complete denture in the maxilla, was referred

to the clinic because of her concerns about

her appearance, speech, and difficulty in

chewing. Patient 3, a 52-year-old, was referred

to the clinic with a complaint of loose and ill-

fitting complete maxillary and mandibular

dentures.

Informed consent was obtained from

each patient before they participated in the

study. The patients underwent alveolar ridge

distraction using intraoral extraosseous de-

vices (Table). There was no relevant systemic

history for the patients. Distraction was

performed in the mandible of all patients.

In patient 1, segmental atrophy was located

at the anterior region (incisor region). In the

other 2 patients, segmental atrophy was

located at the posterior parts of the mandi-

ble (premolar-molar regions) (Table).

Surgical procedure

The surgical procedures were performed

under local anesthesia in all patients. The

vestibular bone was exposed by a horizontal

paracrestal incision, preserving the crestal

and oral soft tissues for blood supply of the

latter bone segment. Lateral release incision

allowed for buccal mucoperiosteal flap

elevation providing access to the prospec-

tive osteotomy site. Careful subperiosteal

dissection was performed to obtain ade-

quate visibility of underlying bone but to

preserve the lingual or palatal pedicle after

the osteotomy was performed. The outline

of the osteotomy was marked with a fissure

bur before adaptation of the distractor, and

the distraction vector was slightly directed to

the vestibular aspect. The osteotomy was

performed using a reciprocating saw, and

the transport segment was finally mobilized

with an osteotome. After the bone segments

were mobilized, the distractor was then

applied, fixed, and temporarily activated to

Distraction Osteogenesis: Case Reports

184 Vol. XXXVII/Special Issue/2011

test for movement of the distracted seg-

ment. Subsequently, the distracted segment

was repositioned to its initial position and

then the surgical incision was sutured with

4/0 silk sutures, leaving part of the distractor

passing through the incision.

The patients were given postoperative

instructions to maintain a liquid or pureed

diet for 1 month and to progress to a soft

diet after that. Antibiotics were prescribed

for a maximum of 10 days (clindamycin 3 3

600 mg), twice a day. The patients were also

provided with an analgesic to be used on an

as-needed basis. Chlorhexidine gluconate

0.12% mouth rinse 15 mL twice daily was

used for 2 weeks postoperatively.

Standard panoramic radiographs were

performed at the first postoperative days

(Figures 1c, 2c, and 3c). After the latency

period (7 days) for initial healing, the

distractors were activated by turning the

screw of the rods at a rate of 1 mm/d in 2

activations for 10 days. The distraction

device was left in position for a 12-week

consolidation period. At the end of this

period, the rod and plates were removed

under local anesthetic. Soft-tissue closure

was once again done in a similar manner

(Figures 2d and 3d).

In patients 2 and 3, the distraction

regenerate was well ossified and stable.

The healing period proceeded without com-

plications. The patients reported no pain or

discomfort and tolerated the procedure well.

However, in patient 1, lingual tipping of the

distraction vector in the anterior mandible

FIGURE 1. (a) Radiograph showing the alveolar deficiency of the patient. (b) Insufficient alveolar crestheight of the patient. (c) Radiograph showing the distracted segment. (d) Ball attachments afterdistraction osteogenesis. (e) Radiograph taken after implant insertion. (f) Intraoral view of the patientat the end of the prosthodontic treatment.

Ergun et al


occurred during the distraction phase. Then,

5 weeks later, a subsequent osteotomy of

the newly formed bone and transport

segment was performed, and they were

fixed in a labial position with plates and

screws.

Radiographic evaluation

Treatment results of the distraction osteo-

genesis were evaluated by means of pano-

ramic radiographs. The distance between the

upper edge of the lower plate and the

alveolar crest was measured after the dis-

tractor was inserted and at the end of the

distraction period. The difference in the two

heights revealed the vertical distracted bone

gain. The distance between the inferior

margin of the mandible and the alveolar

crest was assessed so that alterations in

bone height could also be observed after

distractor removal. The difference between

the bone height immediately after distrac-

tion and final bone height at the end of

consolidation period represented the bone

relapse.8

The mean gain in the vertical height of

bone obtained immediately after the distrac-

tion procedure was 8.1 mm. However, all

patients had bone relapse after the consol-

idation period (mean bone relapse 5

1.83 mm or 22.6%). After the distraction

period, vertical bone gains of 6.3 mm,

6.4 mm, and 6.1 mm were recorded for

patients 1, 2, and 3, respectively (Table).

Based on the prosthodontic planning,

radiographic splints with tooth setup were

made. The treatment plan consisted of

establishing a correct vertical dimension

FIGURE 2. (a) Radiograph showing the alveolar deficiency of the patient. (b) Insufficient alveolar crestheight of the patient (left and right side of the mandibula). (c) Radiograph showing the distractedsegments. (d) Left and right distractors with plates screwed to the bone and distraction rod placed. (e)Radiograph taken after prosthodontic treatment. (f) Intraoral view of the patient at the end of theprosthodontic treatment.



with a fixed implant. The patients were given

a detailed explanation concerning the pres-

ent state, procedures, and alternative treat-

ment plans, and then informed consent was

obtained from the patients.

In patient 1, treatment with mandibular

implant-supported overdenture prosthesis

retained with ball attachments was planned.

Thus, 2 implants spaced 12 to 16 mm apart

(edge to edge) were placed in the lateral

region to the distracted anterior mandible.

Previously, the patient had needed a vestib-

uloplasty with a cutaneous soft-tissue graft

before loading the implant to obtain ade-

quate vestibular depth and keratinized tissue

around the implants. The abutment connec-

tion was delayed for 6 months after place-

ment of the implant.

In patient 2, fixed mandibular reconstruc-

tion with 6 implants (second molar, first

premolar, canine) with 3 independent fixed

partial dentures (right molar to right premo-

lar, right canine to left canine, left molar to

left premolar) was planned. Similarly, in

patient 3 fixed mandibular reconstruction

with 6 implants (second molar, second

premolar, canine) and 3 independent fixed

partial dentures (right molar to right premo-

lar, right canine to left canine, left molar to

left premolar) was planned. In patients 2

and 3, fixed maxillary reconstruction with 8

implants (second molar, first premolar, ca-

nine, and central incisor) and 4 independent

fixed partial dentures (molar to premolar,

canine to central incisor, bilaterally) was also

planned.

FIGURE 3. (a) Radiograph showing alveolar deficiency of the patient. (b) Initial appearance of the patientwith removable maxillary and mandibular dentures. (c) Radiograph showing the distracted segmentand maxillary implants. (d) Left and right distractors with plates screwed to the bone and distractionrod placed. (e) Radiograph taken after implant insertion. (f) Intraoral view of the patient at the end ofthe prosthodontic treatment.

Ergun et al


The surgeon used a custom surgical

guide to help place the implants. The

marginal bone of the implants was evaluated

by periapical radiographs. Furthermore, each

radiograph was calibrated using the known

width of the coronal cylinders of the

implants. In total, 6 implants were inserted

in the distracted areas. In addition, 8

implants were inserted in the maxilla of

both patients. The implants were submerged

and uncovered 4 months later for healing

screws and abutments to be inserted.

Prosthetic phase

In patient 1, an implant-retained removable

prosthesis with ball attachments to the

mandible and a complete denture to the

maxilla were planned (Figure 1d). After

removal of the cover screws (ITI, Straumann,

Basel, Switzerland), impression copings (ITI)

with appropriate diameters were placed. The

impression of the alveolar mucosa was made

with a zinc oxide eugenol impression paste

(Cavex, Cavex Holland BV, Haarlem, Nether-

lands). After the dentures were fabricated, ball

attachments were connected to the fixtures in

the mouth. Retentive components were then

placed on the abutment and undercuts were

blocked out. Venting holes were prepared in

the overdenture for expressing excess acrylic

resin. Upon removal of the denture, irregular-

ities and voids in the intaglio surface of the

TABLE

Characteristics of 3 patients who underwent bidirectional alveolar distraction

PatientNo.

Age(Years) Sex

Region ofTooth Loss

and SegmentalAtrophy Distractor

Bone Gain(mm) No. and Type of Implants Placed

1 70 F Mandibularanterior

Intraoral verticalbidirectionaldistractor*

6.3 2 ITI implants:4.1 mm diameter, 10 mm

long2 55 F Mandibular

posteriorIntraoral vertical

bidirectionaldistractor*

6.4 ITI implants

Maxilla: 8 implants:3 implants: 3.8 mm

diameter, 12 mm long3 implants: 4.1 mm

diameter, 12 mm long2 implants: 3.8 mm

diameter, 10 mm longMandible: 6 implants:

4 implants: 4.1 mmdiameter, 12 mm long

1 implant: 3.8 mmdiameter, 10 mm long

1 implant: 4.8 mmdiameter, 12 mm long

3 52 F Mandibularposterior

Intraoral verticalbidirectionaldistractor*

6.1 MIS`

Maxilla: 8 implants:3.75 diameter, 11.5 mm

longMandible: 6 implants:

2 implants: 3.30 diameter,13 mm long

2 implants: 4.20 diameter,11.5 mm long

2 implants: 3.75 diameter,11.5 mm long

*Modus ARS 1.5, Medartis, Basel, Switzerland.Straumann, Basel, Switzerland.`MIS Implant Technologies Ltd, Shlomi, Israel.



denture around the attachments were filled in

with additional acrylic resin (Vertex, Vertex-

Dental BV, Zeist, The Netherlands). Excess

acrylic resin was removed; the complete

dentures were polished and inserted in the

maxilla and mandible.

In patient 2, extractions of the existing

mandibular canines were planned because

of mobility and occlusion plane problems.

After these teeth were extracted, a fixed

prosthetic denture in the form of a full-arch

bridge was planned for both jaws. In patient

3, the decision was also made to fabricate a

cement-retained fixed partial denture for

both jaws. After the placement of impression

copings, definitive impressions of the maxil-

lary and mandibular implants were made

using transfer copings and a polyether

impression material (Impregum, 3M Espe,

Seefeld, Germany). The impression copings

were fixed onto the abutment analogs.

Cement-retained prostheses were then com-

pleted on abutment-level models from a

base metal alloy (Master-Tec, Ivoclar Viva-

dent AG, Schaan, Liechtenstein) and porce-

lain (VITA VM 13, VITA Zahnfabrik, Bad

Sackingen, Germany) and cemented to the

abutments.

Follow-up and criteria for success

Routine clinical assessments were made 1, 2,

6, and 12 months after prosthetic loading

and then annually with visual and radio-

graphic examinations. Criteria for success

included the following: effective placement

and primary stability of the planned implant,

stability of the implant (lack of mobility),

absence of pain or any subjective sensation

at each visit, lack of peri-implant infection

with suppuration, and lack of continuous

radiolucency around the implant.9 Routine

radiographs consisted of panoramic radio-

graphs taken preoperatively (Figures 1a, 2a,

and 3a), after the distraction osteogenesis

(Figures 1b, 2b, and 3b) and placement of

implants (Figure 3e), at the time of prosthet-

ic loading (Figures 1e and 2e), and annually

thereafter until the end of follow-up. The

initial appearance of the patients (Fig-

ures 1b, 2b, and 3b), the intraoperative view

after distraction osteogenesis (Figures 1d,

2d, and 3d) and final outcome of the

prosthodontic treatment are shown in Fig-

ures 1f, 2f, and 3f.

DISCUSSION

Alveolar distraction osteogenesis has been

considered as an alternative to many other

surgical techniques, such as bone augmenta-

tion for implant-supported oral rehabilitation

of atrophic jaws, alloplastic graft augmenta-

tion, and guided bone regeneration.2,4,8,10,11

Moreover, this technique offers some advan-

tages because it avoids donor-site morbidity

and provides predictable gain of hard and

soft tissues. Further advantages are the low

infection rate and decreased bone resorption.

Moreover, this technique allows the use of

complementary regeneration techniques

when the outcome is not completely satis-

factory.10 Because of these advantages of the

alveolar distraction osteogenesis, the tech-

nique was chosen for this clinical report.

Alveolar distraction osteogenesis also

provides a short bone-consolidation period

before implantation.12 Previous studies re-

ported a mean time of 6 to 8 months after

guided bone regeneration, which is much

longer than the time required after distraction

osteogenesis.12,13 Various consolidation times

have been reported for distraction osteogen-

esis, but 3 to 4 months is typically adequate

for maturation of the distraction regenerate.1

Similarly, in the patients in the present case

report, the consolidation period after alveolar

distraction was 3 months on average. The

advantages of distraction osteogenesis have

been confirmed by the present clinical report.

A number of complications that could

arise with the distraction process include

resorption of the transport segment, difficulty

Ergun et al


in completing the osteotomy on the lingual

side, excessive length of the threaded rod,

bone fracture, device failure, tipping of the

transport segment, perforation of the mucosa

by the transport segment, and inadequate

length of distraction.10,14 Relapse and long-

term results in alveolar distraction have been

reported in several clinical studies.15,16 The

bone relapse occurs because of scar-tissue

contraction after distraction. A consolidation

period of 3 months is generally accepted to be

sufficient to avoid most of the relapse due to

scar contraction.16 A previous study by Ettl

and colleagues8 reported a mean vertical

bone gain of 6.4 mm and an average bone

relapse of 1.8 mm (21.1%) after a consolida-

tion period of 18 weeks. Furthermore, in

another study, the mean bone gain of

6.5 mm and an average bone relapse of

1.6 mm (25%) after a consolidation period of

810 weeks have been recorded.17 In accord-

ance with the previous studies, in the present

clinical report, after a consolidation period of

12 weeks, a mean bone gain of 6.3 mm and an

average bone relapse of 1.8 mm (22.6%) were

recorded. The bone relapse could be partly

attributed to smoothing of the alveolar crest

prior to insertion of the implants. Eventually,

adjustment of the distraction protocol to

include overcorrection of 1525% may com-

pensate the bone relapse during the consol-

idation period of the distracted alveolar

bone.8,18

Another complication that has frequently

been encountered after distraction osteo-

genesis is the displacement of the transport

segment. In a previous study by Ettl and

colleagues,8 33 complications were observed

in 36 patients. In 15 patients (4 maxilla and

11 mandible), oral displacement of the

transport segment occurred, and corrective

osteotomy of the distracted bone segment

and vestibular augmentation were per-

formed. Accordingly, in the present clinical

report, in patient 1, the vector of distraction

was lingually oriented, resulting in the

regenerated bone being positioned lingual-

ly. To place the implants in the right position,

an additional corrective osteotomy was

performed. An incorrect vector of distraction

could be explained by the tension caused by

surrounding cheek and tongue muscles,

together with the traction of the perioste-

um.8,19 Moreover, the soft-tissue complica-

tion that resulted in a reduced vestibular

sulcus might be the result of inadequate

fixed gingiva formation after surgical proce-

dure. Therefore, a full-thickness vestibular

incision in the lower vestibule might be

useful to prevent these complications.

A variety of intraosseous and extraosse-

ous devices are available for alveolar dis-

traction osteogenesis.20 A previous study by

Wolvius and colleagues18 indicated that the

solution for optimal vector management is

the bidirectional extraosseous alveolar dis-

tractor. The extraosseous devices in the

cases presented here allowed good stability

of both the device and the bone segment

during the distraction and consolidation

periods. Furthermore, the distraction rates

were 1 mm/d, performed in 2 activations for

10 days. A previous study by Walker20

indicated that the greater the frequency of

activation, the more favorable the distraction

regenerate. The distraction rate for the

patient presented in that study was also

1 mm/d, performed in 3 activations.

A major esthetic concern with alveolar

distraction osteogenesis is obtaining a pre-

dictable position of the transosteal portion

of the implant in relation to the newly

generated bone ridge crest.21 However, in

the present clinical report, alveolar distrac-

tion processes were performed in the

posterior part of the mandible in patients 2

and 3. As esthetics is of less concern in the

mandible, no esthetic complications oc-

curred in either case. In addition, in patient

1, satisfactory results from esthetic and

functional standpoints were acquired via

implant-supported removable prosthesis.



The decision about when distraction osteo-

genesis can be performed should be based on

the severity of alveolar bone loss. Furthermore,

complications like oral displacement of the

transport vector and inadequate soft-tissue

extensions after distraction may arise. There-

fore, long-term evaluation of a large number of

patients will be necessary to evaluate the

efficacy of this treatment protocol.

CONCLUSIONS

This clinical report has documented the

creation of adequate height and volume of

bone for rehabilitation of the patients with

endosseous implant-supported dental resto-

rations. Although distraction osteogenesis

seems to be a promising method for mandib-

ular reconstruction, it has some limitations.

Bone relapse, displacement of the transport

segment, and soft-tissue complications may

occur after distraction osteogenesis. Thus, the

potential complications and the traction by

muscle forces on the floor of the mouth have

to be considered carefully. Moreover, further

research with more patients is needed to

demonstrate a generalized trend.

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