No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Distraction osteogenesis in maxillofacial surgery
... Las causas más comunes de los defectos alveolares son la avulsión traumática, las resecciones tumorales, atrofia alveolar por la edad, la fisura palatina y la enfermedad periodontal. (3,(5)(6)(7) A pesar de los esfuerzos realizados por nuestro país, estas afecciones continúan siendo un importante problema de Salud Pública, ya que aumenta la morbilidad por lesiones traumáticas y oncológicas del complejo bucal y se incrementan los niveles de desdentamiento de la población (53,3 -67.1%, según grupo etáreo analizado), y con ello de atrofia alveolar que impide o dificulta el uso de prótesis dental con toda una serie de secuelas psicológicas, estéticas y funcionales que limitan al individuo como ser social y en su calidad de vida Estas patologías afectan al tejido óseo y a los tejidos blandos. La distracción tiene la capacidad de reconstruir simultáneamente ambos tipos de tejidos. ...
... La distracción tiene la capacidad de reconstruir simultáneamente ambos tipos de tejidos. (5,8) Otras opciones terapéuticas para la solución de este tipo de patología son los injertos superpuestos o en onlay sobre el reborde alveolar, pero sufren una reabsorción casi total a los dos años cuando sobre ellos se coloca una prótesis mucosoportada. Si sobre estos injertos se insertan implantes osteointegrados, se mantiene la altura por los estímulos que recibe el hueso. ...
... Este desarrollo plantea interrogantes, para cuya solución es fundamental considerar también los aspectos éticos. (2)(3)(4)(5). ...
An important aspect of the scientific progress is the experiment. Therefore, the medical sciences have to lean on this to incorporate new technologies, diagnostic and therapeutic to the clinical practice; validating their security and effectiveness in animals and human beings. The ethics of the experimentation with human being is not only one of the fundamental areas of bioethics, but also one of the problems that brought about its origin. Some ethical implications and social aspects of the experimentation in human beings are described in this work, particularly while talking about the incorporation of a high technology in the ostegenic distraction in maxilofacial surgery for the reconstruction of defects combined in hard and soft fabrics; the origin and evolution of bioethics are analysed, the regulatory aspects for the realization of clinical rehearsals and their moral valuation, the experimentation types; the world and Cuban reality as for clinical investigation and technology and the informed consent. As a conclusion it is said that the fundamental ethical approach of the investigations in human beings is its disposition to the man's service as a goal and never as a way
... In DO, an osteotomy line is gradually stretched, thus promoting osteogenesis and expansion of the overlying soft tissues. 1 During the past 20 years, DO has emerged as a useful alternative for the management of skeletofacial insufficiencies. ...
... The main advantage of osteodistraction is its capability of promoting, at the same time, correction of bone defects and expansion of soft tissues. 1,3,[42][43][44][45][46][47] The tensional stress applied to bone determines adaptive changes on the adjacent soft tissues, in a process that could be appropriately named distraction histogenesis. 2,3 According to Loboa et al, 48 the daily tension made by the distraction device causes little trauma to the tissues, thus activating neoformation of mesenchymal tissues. ...
... 17,31 Bone exposi-tion and implant placement are recommended 10 to 16 weeks after the end of the activation period. 1 Dual purpose devices, which are distractors and implants at the same time, simplify the procedure and reduce chair time. 58-61 DO can even be used for repositioning misplaced implants. ...
Management of skeletal deformities in the maxillofacial region has been an important challenge for medicine and dentistry throughout their evolution as health care sciences. Distraction osteogenesis (DO), also referred to as osteodistraction, is a surgical technique that uses the body's own repairing mechanisms as allies for optimal tissue reconstruction. This method has gained acceptance and joined the conventional techniques for comprehensive treatment of patients with skeletal insufficiencies, and its successful application in the maxillofacial complex has been extensively reported. The primary aim of this article is to summarize the information on DO, thus contributing to its study, development, and application in challenging situations of our clinical practice as oral and maxillofacial surgeons.
... These deformities were managed by a variety of surgical techniques, such as autogenous on lay bone grafting, alloplastic augmentation, connective tissue grafting or guided tissue regeneration. Each of these modalities, however, had their limitations [64,65]. ...
Abstract
Distraction osteogenesis (DO), also called callus distraction, callotasis, osteodistraction, and distraction
histogenesis is a biological process of regenerating neo formed bone and adjacent soft tissue by gradual and
controlled traction of the surgically separated bone segments. Physical and biological parameters affecting the
success of DO include the macro and microscopical bone anatomy, the direction and amount of the applied
distraction forces, and the regenerative capacity of the tissues involved. Force transduction via adjacent structures
(joints, ligaments, muscles, and soft tissue) influences the regeneration of the tissue between the bone fragments by
modulating the stress produced within the callus. The clinical applicability of DO is dependent upon device-related
and tissue-related factors. Device-related factors affect the mechanical integrity of the distractor and the stability of
bone fixation. The number, length, and diameter of fixation pins, the rigidity of the distractor fixation, and the material
properties of the device affect the clinical result of the distraction procedure, additionally, the orientation of the
distraction device and the resulting distraction vector relative to the anatomical axis of the distracted bone segments.
In case of the jaws – the occlusal plane and the joint position are important considerations. Tissue-related factors
affecting the quality of the generated distraction tissue include cross-sectional area, the density of the distracted
bone segments, the length of the distraction gap, and the tension of the soft tissue envelope. In the maxillofacial
skeleton, DO replacing many of the traditional surgical treatment for Congenital and acquired deformities. Here, the
Biomechanics of DO and its Clinical Implications in the maxillofacial skeleton will be discussing.
... Each of these modalities, however, had their limitations. [33,34] Alternatively, osteodistraction of the alveolar process provides superior reconstruction of these types of defects. Block and coworkers established the validity of distraction osteogenesis for alveolar ridge augmentation in canine mandible. ...
An attempt has been made to review various devices as well as the outstanding studies done in the past for understanding the methodology of distraction for regeneration of bone. Lengthening of underdeveloped bones inclusive of the maxillofacial complex has been obtained by distraction osteogenesis by many authors. This could be achieved by the use of various extraoral or intraoral devices. Devices used for distraction osteogenesis must have a minimum of 2 important characteristics - they should be able to transfer distraction forces directly to the bone and secondly, should offer adequate rigidity for osseous consolidation to occur. With advanced technology and biomechanical engineering, preformed intraoral distraction devices are now available worldwide. The introduction of these intraoral bone-bourne devices have eliminated the need for bulky, cumbersome extraoral distraction devices which had problems such as external scars, pin tract infections, nerve or tooth bud injuries and poor patient compliance. The design of completely internalized custom made appliance has opened new vistas in the field of Oral and Maxillofacial Surgery. Indigenous internal devices are also economical and locally available.
... In order to avoid vascular risk and guarantee the solidity of the system, it was decided to displace the entire graft rather than limit above it to provide support. Since only nasal mucosa remained above the graft once it was freed, it was necessary to find a substitute for the missing bone structure without which commercial vertical distracters (Chin and Toth, 1996; Gaggl et al., 1999) could not be used (Fig. 1A, 1B, 1C, and 1D). CASE REPORT This technique was applied in the treatment of a 16-year- old girl. ...
Presentation of a specific surgical technique of vertical alveolar ridge distraction performed on an alveolar bone graft 1 year after the primary grafting procedure designed to correct a labioalveolar cleft. The graft had not obtained the results desired and presented heavily scarred mucosal tissue.
A dental implant placed within the graft once it has been entirely freed by osteotomies functions as an endless screw. To avoid vascular risk, the alveolar bone graft is detached as a whole along its total height. Consequently, no bone remains above it to provide support for a conventional alveolar distractor. An osteosynthetic miniplate, fastened in a horizontal position beneath the nasal mucosae above the graft, is used to replace the missing bony support and to stabilize the implant, which activates the distraction process.
This study is based on our first clinical case with a follow-up of 18 months at present.
A vertical displacement of the entire graft was achieved, including its attached mucosal layer, which repositioned both bone and mucosa on a far better level in the cleft area. Thus, a normal length of abutment was obtained permitting prosthetic rehabilitation based on the same endosseous implant, which was left in place within the graft.
This technique may prove particularly helpful in certain cases in which a primary alveolar bone grafting procedure has produced borderline results. In such cases, on the one hand, neither the reasonably satisfactory volume of the bone graft itself nor the poor quality of its scarred mucosal tissue argue in favor of a secondary grafting procedure. On the other hand, it is impossible to resort to currently available alveolar distracters since our choice of techniques leaves no bone support above the graft.
... [4][5][6] More recently, distraction techniques have been applied to the facial bones and soft tissues, [7][8][9][10][11][12][13] including use in the treatment of inadequate height of the alveolar ridge. [14][15][16][17][18][19] Alveolar distraction osteogenesis promises to have very useful applications in the field of implantology, particularly in cases of mandibular alveolar hypoplasia. In such cases, the lack of sufficient bone height between the alveolar canal and the alveolar rim means that the implant must be short; at the same time, the reduced height of the rim means that the crown must be long. ...
This study evaluates complications that arise during mandibular alveolar distraction osteogenesis and suggests treatments.
We monitored complications that arose during alveolar distraction osteogenesis in 5 patients who underwent a total of 7 distractions, in all cases using an intraosseous distractor (Lead System, Leibinger, Germany). We report our responses to each type of complication.
All 7 distractions were followed by the placement of 2 implants. The restoration was ideal in 4 of the 7 cases and functional but not ideal in the remaining 3. In all 7 distractions, we observed complications, although many were minor complications readily avoided by the use of appropriate technique. The complications were, first, intraoperative complications, namely 1) fracture of the transport segment (1 of 7 cases; Response: appropriate preventative measures), 2) difficulties in finishing the osteotomy on the lingual side (7 of 7 cases; Response: use of fine chisels made from cement spatulas), and 3) excessive length of the threaded rod (1 of 7 cases; Response: cut the rod). Second, complications arose during distraction: 1) incorrect direction of distraction (2 of 7 cases; no corrective measures necessary in the present cases), 2) perforation of the mucosa by the transport segment (2 of 7 cases; response: smooth the crest of the segment with a bone rongeur), and 3) suture dehiscence (1 of 7 cases; no significant implications). Third, there were postdistraction complications, namely bone formation defects (4 of 7 cases; response: guided bone regeneration).
A number of complications may arise during alveolar distraction osteogenesis. Most of these complications can be considered minor and are readily avoided or resolved by the use of appropriate procedures.
Bioengineering of bone represents a rapidly evolving frontier of craniofacial reconstruction. The combination of powerful morphogens, scaffolds, templates, and mesenchymal cells capable of assuming an osteogenic fate can produce a biomaterial which can induce its own blood supply and thereby escape the constraints of vascularized bone flaps. This chapter describes selected aspects of this field from a perspective derived from early work with recombinant human bone morphogenetic protein-2 and connecting forward to autologous adipose-derived mesenchymal cells. This discussion is designed to serve as a springboard for further innovation by readers with an interest in stem cell biology and tissue engineering. The learning objective is to unleash your own imagination.
Objectives
To present the clinical, radiographic, and patient‐related outcomes of patients presenting with severely resorbed ridges reconstructed with autogenous calvarial bone blocks and rehabilitated with implant‐supported prostheses.
Material and methods
From 1998 to 2014, 72 patients presenting with severe bone defects were reconstructed with autogenous calvarial bone blocks covered with bovine bone mineral granules and collagen membranes. Four to 9 months later, 330 implants were placed and loaded 3–9 months later. The follow‐up ranged from 3 to 19 years (mean: 8.1 years). The following parameters were recorded: (a) complication rate of the reconstructive procedure; (b) bone resorption before implant placement; (c) implant survival rate and implant‐related complications; (d) peri‐implant bone resorption; and (e) patient's satisfaction inquired with a dedicated questionnaire.
Results
No patients developed severe complications, such as complete loss or resorption of the grafts. A dehiscence occurred in six patients, which developed a mild graft resorption. The mean peri‐implant bone resorption before implant placement was 0.13 mm (SD ± 0.71). All patients received the planned number of implants. Three patients were lost during the follow‐up. The survival rate of implants at the end of the observation period was 98.5%. The mean peri‐implant bone resorption ranged from 0.00 to 4.87 mm (mean: 1.11 mm). At last, 90% of the patients were very satisfied as regards the treatment received.
Conclusions
Results from this study suggested that: (a) bone volume in the areas reconstructed with calvarial grafts was stable over time; (b) survival rates of implants were consistent with those reported for implants placed in native bone; (c) patient's satisfaction was high.
s
Purpose
The aim of this retrospective study was to compare the performance of implants placed following alveolar distraction osteogenesis (ADO) or autogenous onlay bone graft (AOBG) based on implant survival, peri-implant bone resorption and clinical parameters.
Materials and methods
From February 2008 to July 2012, 17 patients (6 females and 11 males) with implant placement following ADO (group 1, 8 patients) or AOBG (group 2, 9 patients) were included in this retrospective study. In all, 37 implants were placed in group 1 and 22 implants were placed in group 2. Implant survival rate, peri-implant bone resorption, probe depth (PD), the modified plaque index (mPI), and the modified sulcus bleeding index (mSBI) were analyzed to evaluate implant prognosis.
Results
Successful reconstruction of vertical alveolar defects and uneventful implant placement were achieved in all patients in both groups. After a mean follow-up time of 47.9±13.3 months, the implant survival was 97.3% (36/37) in group 1 and 95.5% (21/22) in group 2. No statistically significant differences were observed. The peri-implant bone resorption was 1.29±0.59 mm in group 1, which was slightly higher than the 1.24±0.87 mm in group 2 at last follow-up. The difference was also not statistically significant. Favorable peri-implant conditions were indicated by PD, mPI and mSBI in both groups.
Conclusions
Both ADO and AOBG could be used for correction of vertical alveolar defects with reliable implant prognosis. Comparably high implant survival rates and favorable peri-implant conditions were attained.
This chapter discusses ridge expansion (RE) with osteo-mobilization combined with trans-alveolar sinus elevation (TASE) procedures for simultaneous restoration of posterior maxillary alveolar ridge width and height. It reviews rationale, clinical indications, and applications for these procedures, including flap design and soft tissue enhancement techniques. RE techniques can be broadly categorized as osteo-condensation and osteo-mobilization. Preoperative clinical evaluation and treatment planning considerations should include smile assessment, attached gingival tissue (width and biotype), vestibular depth, and muscle or frenal tissue attachments. Bone quantity and quality vary greatly in the edentulous maxilla and require careful preoperative clinical and radiographic analyses. Full-thickness flap exposure can be used in conjunction with osteotome techniques and particulate over-grafting for a single- or two-stage implant placement protocol. Partial-thickness flaps help preserve the vascular supply to the buccal bone flap, helping to limit bone resorption of the expanded segment.
This chapter reviews the scientific basis, clinical indications, and applications for bone manipulation to achieve ridge expansion (RE) in a minimally invasive manner, including appropriate flap designs and soft tissue enhancement techniques for esthetic dental implant reconstruction. Significant differences in terminology and technical difficulty with the broad group of procedures described as "RE" may account for the varied reports of success and complications. Evaluation of facial, dento-facial, and dento-gingival parameters and esthetics must be completed prior to initiating an RE procedure. Treatment planning considerations should include smile assessment, quality and quantity of keratinized gingival tissue (width and biotype), vestibular depth, muscle or frenal tissue attachments and adjacent teeth or implants at the intended surgical site. In mandible, osteo-condensation with full-thickness flap exposure and rotary screw expanders offers a similar minimally invasive approach.
Over the last two decades, the technique of alveolar distraction osteogenesis (DO) has gained significant advancement. Several animal and human clinical studies have proven its efficacy in augmenting alveolar bone and soft tissue defects. This chapter describes a brief history, rationale, indications, and contraindications of using alveolar DO. It further emphasizes the surgical treatment planning principles, phases of alveolar DO, and management of complications associated with alveolar DO.
The loss of teeth, which is a frequent occurrence, is followed by functional, aesthetic and psychological problems. Dentistry has very important role to enable adequate rehabilitation as soon as possible. Removable dentures or fixed bridges on dental implants are most modern and best mode of rehabilitation for the patient. The advantages of implant anchored tooth restorations compared with classical procedures are multiple. Among others, there is prevention of bone resorption, correction of the stability and retention of the restorations, elimination of the preparation of adjacent teeth, as well as the improvement of the patient's psychological status. In order to achieve successful implantation, the following principles have to be taken into consideration: indications and contra indications; biocompatibility; osseointegration; the protocol of implant loading and the assessment of implant success. One of the biggest challenges is implantology under unfavourable anatomical conditions, as well as the implantation on irradiated tissue. However, these conditions are not absolute contraindications for implantation. The adequate choice of adequate implantological system enables successful implantation under different conditions.
La distracción ósea es una técnica quirúrgica con la que diferentes deformidades craneofaciales se pueden corregir. Las craneosinostosis y su compleja expresión clínica en la cara y en el cráneo, hoy en día son factibles de tratarse utilizando diferentes osteotomías donde se incluye el frontal, órbitas, los malares y el maxilar, para luego realizar el avance planificado con distracción ósea. Cuando este procedimiento se hace en forma asistida con métodos endoscópicos se produce menor morbilidad bajando en forma muy importante la tasa de complicaciones y resolviendo en forma muy satisfactoria la deformidad frontal, el exorbitismo, la hipoplasia malar y la re trusión del tercio medio en estos pacientes. Como la distracción es un proceso gradual, la resistencia de los tejidos blandos al avance se puede vencer fácilmente lográndose grandes avances en sentido anteropostero que fluctúan entre 16 y 32 mm., en el frontal y entre 9 y 16 mm., en el maxilar. Los avances óseos se mantienen por el hueso neo formado sobre las líneas de osteotomías y los cambios estético-funcionales son muy satisfactorios.
Objective: To study the role of the periosteum and endosteum in new bone formation by distraction osteogenesis.Materials and Methods: Twenty four rabbits were divided into 3 groups of perieosteum destruction (group P), endosteum destruction (group E), and a control group (group C). After right mandibular body osteotomy followed by distractor placement, the buccal periosteum in the segment between the second and third screws was removed by scalpel in group P. In group E, the endosteum was scraped out from both bone ends between the second and third screws. In group C both periosteum and endosteum were preserved during the surgical operation. After a latency period of 3 days, bone lengthening was started at a rate of I mm per day for 10 days, after which the newly formed bone was allowed to consolidate for 6 weeks with the device serving as an external fixator Radiographs were taken at the following time intervals: 2 weeks, 4 weeks, and 6 weeks after completion of distraction and 6 months after consolidation. The animals were sacrificed 6 weeks after completion of distraction and 6 months after consolidation for the gross macroscopic, histological, and radiological examinations and stability measurement of the distracted segment.Results: New bone was generated in all animal groups. The buccal cortex was incompletely formed in groups P and E but was completely formed and indistinguishable in the control group after 6 months. Histologically, the newly formed bone in the control group had a more mature appearance and better organised bone spicules than in groups P and E. In addition the remodelling process occurred more rapidly in the control group. However, quantitative analysis of the newly formed bone by densitometry revealed no statistically significant differences at each time interval among the 3 groups except for a decline in density in the control group after 6 months due to the bone remodelling process. The stability of the regenerated bone of the lengthened segment was best in the control group, with groups P and E showing marked changes in the length of the distracted distance.Conclusion: Although groups P and E exhibited slower new bone maturation, the amount of newly formed bone was equal in all groups. It could be stated that the periosteum and endosteum are probably not indispensable or particularly important for adequate callus formation. This may be due to the rich blood supply of the craniofacial skeleton. However the instability of the segment caused by the slow maturation and remodelling of the newly formed bone in groups P and E should be noted, and a longer consolidation period is recommended to avoid instability of the regenerated segment in such cases.
Recently, surgeons have begun to treat serious congenital craniofacial deformities including craniosynostoses with mechanical devices that gradually distract the skull. As a prospective means of treatment planning for such complex deformities, FE models derived from routine preoperative CT scans (CT/FEA) would provide ideal patient specific engineering analyses. The purpose of this study was to assess the dimensional and predictive accuracy of the CT/FEA process through the development of a D model of a dry human calvarium subjected to two-point distraction ex vivo. Comparative skull measurements revealed that CT/FEA construction error did not exceed 1% for transcranial dimensions, and the thickness error did not exceed 8.66% or 0.31 mm. CT/FEA strain predictions for the central region of the skull, between the distraction posts, were not statistically different from homologous gage values at P
The purpose of this report is to present the application of distraction osteogenesis (DO) to the correction of mandibular deformities. DO is a technique used to lengthen bones after a cut is made within the bone and the segments are gradually separated, creating new bone between them. Elongation of the mandible improves the deficient bone structure as well as the surrounding soft tissues, including muscle and skin. In cases with reduced hypopharyngeal space, mandibular elongation through distraction leads to an enlarged and improved airway. Representative cases are illustrated to show the application of mandibular DO.
There are numerous indications for bone regeneration materials and techniques in the orofacial region. Examples of some typical
indications, as illustrated in Fig. 1, include:
1.
Periodontal bone defects, i.e., osseous defects around teeth
2.
Periimplant defects, i.e., osseous defects around endosseous dental implants
3.
Large, extraction defects following tooth extraction, especially where the buccal plate of bone is missing or damaged
4.
Large defects at the tooth root apex resulting from pulpal infection or a failed root canal procedure
5.
Resorbed or atrophic alveolar ridges
6.
Tumor resection or trauma resulting in osseous defects
7.
Developmental abnormalities
As in the traditional combined surgical and orthodontic procedures, an Orthodontist can plays vital role in treatment planning and the orthodontic treatment of patient undergoing distraction osteogenesis. This role includes predistraction assessment of the craniofacial skeleton and occlusal function, pre-distraction, and post-distraction orthodontic care. Based on clinical evaluation, dental study models, photographic analysis, cephalometric evaluation, and three-dimensional computed tomographic analysis, the Orthodontist, in collaboration with the Surgeon, plans distraction device placement and the predicted vectors of distraction. Finally, as in other forms of orthognathic surgery, the practice of distraction osteogenesis depends on the cooperation and planning between orthodontist and surgeon as a team. Purpose of this paper is to review biomechanics and orthodontic treatment protocol of distraction osteogenesis in the maxillofacial region.
When developmental, traumatic, neoplastic arthritis or ankylosis results in an anatomically unsalvageable, functionally compromised temporomandibular joint (TMJ), total joint replacement (TJR) may provide the only management option. In the adult patient these situations are often dealt with by use of either autogenous or alloplastic modalities. However, any of these pathologic conditions when present in the growing patient present the reconstructive surgeon with not only the concerns of form and function, but also the consideration of adaptive facial growth. 1-3 Classically, pathologic, developmental, and functional disorders affecting the TMJ in children have been reconstructed with autogenous tissues. Autogenous costochondral grafts are reported as the “gold standard” for TMJ reconstruction in the growing patient. 4-8 The use of other autogenous bone/cartilage combinations has also been described in such cases. 9-12 In theory, these autogenous (eg, costochondral) allografts will “grow with the patient”; however, often, this so-called growth potential has been stated to be unpredictable or to result in ankylosis, either as the result of the allograft and/or fixation failure or because of the uncooperative nature of the young patient with physical therapy after reconstruction. 4,5,13-28 Recent studies have even questioned the necessity for using a cartilaginous graft to restore and maintain mandibular growth. 29,30 Long-term reports of mandibular growth in children whose TMJs were reconstructed with costochondral grafts show that excessive growth on the treated side occurred in 54% of the 72 cases examined, and growth equal to that on the opposite side occurred in only 38% of the cases. 26,31-35 Further
To describe a successful clinical case of implant prosthetic rehabilitation in an atrophic posterior mandible reconstructed by inlay bone grafting after bone block harvesting from the mandibular ramus.
A 55-year-old woman with an atrophied right posterior mandible underwent surgical inlay ridge augmentation under local anaesthesia using a block graft harvested from the ipsilateral mandibular ramus. Three months later 3 dental implants were inserted, and after an additional 4 months abutments were connected and a definitive fixed bridge inserted.
After a 24-month follow-up, no implant failure was recorded; the patient was functionally and esthetically satisfied.
The inlay procedure in atrophic posterior mandible, associated with mandibular ramus graft harvesting, may be considered an effective, minimally invasive and well-tolerated procedure for implant prosthetic rehabilitation.
The purpose of this paper is to report long-term results on the use of autologous bone graft and platelet-rich plasma in alveolar distraction osteogenesis (DO) for restoration of severe atrophic mandible. We tested the efficacy as to reabsorption of bone volume, peri-implant reabsorption, implant survival and success rate.
Twelve patients were treated. The surgical procedure consisted in mixing autologous bone, harvested from the iliac crest, with autologous platelet concentrate (APC) and in filling the distraction gap with this graft. After a latency of 15 days, a distraction rate of 0.5 mm/day was followed. After a 60-day period of consolidation, the distraction device was removed and implants were placed simultaneously. The abutment connection was accomplished after 6 months. In addition, every patient was evaluated clinically and radiographically annually for 5 years.
Planned alveolar height was reached in 11 out of 12 patients. The total number of implants positioned was 47. At the time of implant positioning, the mean decrease of total bone volume was 2.3%. The mean peri-implant resorption was 0.40 mm at the time of abutment connection, 0.61 mm 1 year after implant loading and 1.51 mm after 5 years. After 5 years of follow-up, the mean rate of vertical bone loss was 18.7%. Instead, the implant survival and success rates were 97.9% and 91.5%, respectively.
Long-term results allow us to confirm the combination of autologous bone-platelet gel with alveolar DO as an effective and predictable procedure in restoration of severe atrophic mandible.
Over the last 50 years, Ilizarov refined a method to successfully lengthen endochondral bones and the surrounding soft tissue matrix. Given the difficulties in reconstructing deformities of the craniofacial complex, distraction osteogenesis has recently been used to avoid the problems associated with conventional surgery and to begin correction at an earlier age. Distraction devices can be categorized by whether they are internal or external, the direction of distraction, and the site of application. External devices are capable of either unidirectional, bidirectional, or multiplanar (three-dimensional) distraction. Internal or intraoral distractors are capable of unidirectional distraction only. Distraction devices used to lengthen the mandibular ramus and body, widen the mandible, augment the alveolar ridge, conduct bone transport, and advance the midface are reviewed.
This study retrospectively evaluated the long-term effects of transverse symphyseal distraction osteogenesis (DO) on the temporomandibular joint (TMJ) symptoms, periodontal health, tooth vitality, and nerve injury after surgery.
Twenty-three patients were treated with symphyseal DO during a 4-year period. Fifteen patients were available for follow-up from 7 to 45 months postoperatively (ave, 24.5 months). The patients were clinically evaluated for TMJ symptoms, periodontal pocket formation, tooth vitality and mobility, crestal bone loss, and attached gingival tissue changes. Radiographs of the mandibular anterior teeth were used to evaluate for periodontal bone loss, periapical lesions, or widening of the periodontal ligament (PDL).
Preoperatively, 47% of the patients had TMJ symptoms. No patient had symptom worsening or developed new symptoms postoperatively. Five patients' TMJ symptoms improved, and 3 experienced complete resolution of symptoms. No periodontal bone loss or soft tissue recession were evident. Tooth vitality was maintained in 13 patients. Two patients developed Class II mobility of 1 mandibular central incisor, 1 patient had tooth pain and a widened PDL adjacent to the osteotomy/corticotomy site, and 1 patient experienced mental nerve paresthesia.
DO can be used to treat transverse discrepancies of the mandible with limited morbidity.
This report presents the results of distraction osteogenesis using unidirectional extraoral and intraoral devices in 8 patients with different grades of vertical mandibular ramus hypoplasia.
Eight patients with hypoplastic mandibles underwent unilateral lengthening of the ascending ramus using unidirectional extraoral or intraoral devices. Intraoral mandibular distraction was performed on 5 patients with deficiencies of the vertical ramus up to 24 mm. External devices were used in 3 patients with more severe hypoplasias. An intraoral osteotomy was performed, and progressive distraction at rates of 0.5 mm/12 hours was initiated after 5 days. Once the desired length was reached, the device was maintained in place for 8 to 12 weeks. Three-dimensional computed tomography scans were taken in all the patients to plan the procedure and to compare the changes postoperatively.
Successful distraction osteogenesis was achieved in all patients. The amount of mandibular lengthening ranged from 17 to 32 mm. Complications with the external devices such as rotation of the proximal bony fragment (2 cases) and loosening of the external screws at the end of the consolidation period (1 case) were observed.
The results suggest that the intraoral device can be used as the method of choice for distraction osteogenesis of the ascending ramus of the mandible in patients with large deficiencies. Preoperative and postoperative 3-dimensional computed tomographic scans are essential in treatment planning.
Vertical osteodistraction is a new alternative method for alveolar ridge augmentation of the mandible. The purpose of this article is describe a technique using an L-shaped osteotomy and titanium membranes for guided bone regeneration (GBR) in the distraction gap.
Ten patients with severe atrophy of the edentulous molar region of the mandible underwent vertical callus distraction in 13 sites using intraoral microplate distractors. An L-shaped osteotomy with a short vertical part mesially and a longer horizontal part ending in the retromolar region was made, and the osteotomized segment was fixed to the mandibular ramus at its distal edge by a microplate, which became the center of rotation when distraction began. In this way, more callus generation could be achieved mesially than in the distal molar region. Follow-up computed tomography (CT) scans reconstructed axially to the axis of the mandible revealed semilunar excavations of the generated bone buccally in the distraction gap in the first cases. Clinical inspection on removal of the distractors showed fibrous connective tissue in the gap. Therefore, to prevent this from happening, titanium membranes covering the distraction gap were applied in subsequent cases.
Ten patients (13 sites) were treated by vertical callus distraction. In 4 cases, GBR was achieved using titanium membranes. In all cases, the increase in alveolar height was sufficient to make dental implantation possible. In 1 patient, a fracture of the distractor occurred, and dehiscence was observed in 2 cases. These complications did not change the plan of therapy nor did they influence the results. The CT scans showed a homogenous surface on the regenerated mandible in the cases of GBR application.
Both an L-shaped osteotomy and the application of titanium membranes for GBR in the distraction gap are of great value for mandibular augmentation, producing a physiologically shaped alveolar ridge.
The treatment of midfacial retrusion, due to congenital midfacial hypoplasia or trauma, is a challenging problem. Conventional Le Fort III osteotomies, with the surgical mobilisation of the entire midface, offers one solution. Distraction osteogenesis has become an accepted, and often preferred, technique for the treatment of severe midfacial hypoplasia. Existing distraction devices have several disadvantages. To overcome some of these disadvantages, an internal and temporal positioned distraction device was developed.
The new, internal positioned distractor device was used in 5 patients (age range, 8 to 15 years). Nine distractors were used in 4 patients with midfacial retrusion and 1 patient with hemifacial microsomia.
The preoperative planned position of the osteotomized Le Fort III segment was obtained without any complications in all cases. Midface advancement, measured as the anterior displacement of the infraorbital rim, ranged from 14 to 20 mm. The distractor was almost invisible and did not disturb daily activities of the patient. Activation of the distractor was performed by rotation of a small lateral activation rod.
These preliminary results encourage the further use of the new distractor device in a larger series of patients.
We investigated the efficacy of alveolar distraction for reducing crown height:implant length ratio in the posterior mandible. Ten alveolar distractions were done in seven patients. The pre-distraction ratio of required crown height to bone height available for implantation was in all cases > or =1. Two implants were placed in each distracted area (total 20 implants). Before distraction, the mean (SD) predicted crown height was 12.8 (2.1) mm; mean bone height available for implantation was 7.8 (1.5) mm. After distraction and insertion of implants, mean crown height was 8.1 (1.9) mm, and mean implant length was 11.3 (1.9) mm. Before distraction, the mean required crown height:available bone height ratio was 1.7 (0.3); after distraction and insertion of implants, the mean crown:implant ratio was 0.7 (0.2) (P<0.0005). Alveolar distraction is effective for increasing the height of the alveolar ridge in the posterior mandibular region, and should be considered when the height of the predicted crown that is required is greater than or equal to the maximum height of bone available for implantation.
Transport distraction osteogenesis has been used to reconstruct continuity defects by regenerating bone and soft tissues. A challenge has been to maintain the correct vector during the distraction process. A new type of distraction device was recently developed that uses a standard reconstruction plate to "guide" the transported segment of the bone. This plate-guided distractor device (PGD) intimately follows the shape of the plate, thus allowing for 3-dimensional vector control during the distraction process.
Four patients underwent transport distraction osteogenesis for reconstruction of segmental mandibular defects ranging in size from 4 to 7 cm. The age of the patients ranged from 27 to 62 years. Two patients had been treated with radiotherapy as part of treatment for oral malignancy. A standard locking reconstruction plate was placed to bridge the continuity gap. An osteotomy was performed to create a bone transport segment. The PGD was secured to both the reconstruction plate and the transport bone. After a latency period of 7 days, the device was activated at a rate of 1 mm/d. The distraction process continued until the transport segment reached the opposing bone or sufficient bone and soft tissue were reconstructed for oral rehabilitation.
All patients achieved hard and soft tissue formation. Two patients had premature consolidation of the distraction regenerate but had sufficient tissue for rehabilitation.
A PGD can be used to regenerate missing hard and soft tissues. An advantage of this technique is that it uses a reconstruction plate that is routinely placed to bridge mandibular continuity defects. This device allows for ultimate vector control by intimately following a carefully adapted plate.
Recently, alveolar bone distraction has been widely used and several devices have been developed for this purpose. However, there are some disadvantages in each device, especially for distraction of posterior alveolar ridge. The purpose of this study was to develop a new device for vertical alveolar bone distraction at the molar region and to show the results of its clinical application.
The mechanism of device is based on lag screw principle and the device consists of the following 4 components; distraction screw, hole implant fixture, supporting plate, and temporary short implant and/or neighboring natural teeth. The distraction screw suspended at the supporting plate is inserted into the internal thread of the hole implant fixture placed at alveolar transport segment. If the distraction screw turns at the supporting plate, the hole implant fixture with transport segment moves to the supporting plate without vertical movement of the screw at the supporting plate like a lag screw. After an animal experiment using 4 beagle dogs, the device was clinically applied in 4 patients before implant insertion.
The distraction of the alveolar bone could be successfully performed in all patients without any complications. The direction of distraction with this device could be adjustable, and the alveolar bone could be distracted not only vertically but also horizontally. Moreover, the surgical technique is simple with no need for a second surgery, and there is no occlusal disturbance from the device.
The new device for alveolar bone distraction using lag screw principle can be used effectively in the molar region.
The following study illustrates preoperative and perioperative vector management in alveolar distraction using a new distraction system--the "Floating Alveolar Device" (FAD). The FAD is a bidirectional alveolar distractor that allows augmentation of an atrophic alveolar process in several planes, assures easy intraoperative positioning of the planned vector of distraction, and provides correction of the horizontal position of the transported segment during and after vertical distraction.
The FAD is composed entirely of stainless steel and has the following basic components: an upper member, a distraction rod, a lower base plate supporting the vertical force of the distraction rod, a jointed hinge that connects the upper and the lower members, and a tightening rod that provides blocking of the hinge. The clinician can manipulate and adjust the tightening rods, allowing a change in the angle of the hinge, thereby altering the transverse dimension of the vector of distraction. A total of 4 patients aged to 19 to 40 years underwent bidirectional alveolar distraction. All procedures were performed in the mandible.
In all treated patients, planned distraction height and direction were achieved. In all cases it was possible to place implants at the planned time.
The most common complication, axial displacement, is easily eliminated by moving the bone with the "floating" rod of the FAD during or immediately after the distraction period, according to the principles of the floating bone concept.
The purpose of this report was to describe a surgical technique for performing horizontal alveolar distraction of the knife-edge maxillary ridge.
The patient was a 17-year-old woman with atrophy of the alveolar rim in the anterior upper jaw, which had inadequate width for implant placement. The transport segment was constructed by the osteotomy of the labial cortex of the alveolus. A transport plate of a distractor (LEAD system; Stryker Leibinger, Kalamazoo, MI) was placed on the transport segment. The distraction rod was inserted horizontally, and put in contact with the palatal cortex at the top. A base plate was not placed.
The alveolar distraction was successfully performed to gain 6.0 mm in width and 0.5 mm in height, allowing placement of three 14-mm implants. All the implants were integrated so as to support the prosthesis.
Alveolar distraction can be useful for augmenting the narrow ridge horizontally and placement of implants.
Distraction osteogenesis has recently evolved a challenging technique to overcome major drawbacks of conventional augmentation procedures. We, therefore, report the application of miniaturized intraosseous distraction devices for the rehabilitation of mandibular defects due to ablative tumor surgery.
In 10 patients who had undergone box-shaped or segmental resections, augmentation of the residual mandibular bone or of full thickness iliac crest grafts was performed by intraosseous implant-shaped distractors. Distraction and reconsolidation was monitored by ultrasonography. Implants were inserted within 1 week after active distraction. Median follow-up after implant insertion was 38 months.
On average, a vertical gain of 7.3 mm was obtained by distraction. Except for one case (local infection), all distraction zones showed complete ossification by radiologic and ultrasonographic evaluation. Overall 28 implants were placed in the distracted bone. Two implants were lost at 2.4 and 22 months after placement. The estimated 4-year implant survival rate in this population was 90%. For the endpoint 'bone loss' (>1.5 mm in the first and >1 mm in following years), the estimated 4-year success rate was 59% with four out of seven events occurring in a single patient (patient No. 1 of this series).
Vertical distraction by means of implant distractors could be performed with reasonable success in tumor patients with box-shaped resection defects or undercontoured bone grafts. Overall morbidity was very low. Even though blood supply is continuously maintained in distraction osteogenesis, bone resorption remains a critical issue for this reconstruction technique too.
The purpose of this article is to describe the method for reconstructing patients with severe anterior maxillary defects, using a combination of distraction osteogenesis, onlay bone grafts, and implants to support either fixed or fixed/removable prostheses.
The surgical technique involves placement of an extraosseous distraction device followed by greater than 10 mm of distraction of the alveolus. A corticocancellous graft is harvested from the hip to establish sufficient horizontal bone for implant placement. Implants are placed after graft consolidation followed by fabrication of a fixed or fixed/removable prosthesis depending on the needs of the individual patient.
Five patients have been prospectively followed using this technique, with completion of their prosthetic reconstruction, with follow-up ranging from 1 to 4 years.
The combination of distraction, onlay bone grafting, and implant placement has been able to reconstruct patients with severe maxillary defects.
To present the authors' clinical experience with unidirectional internal distraction devices to reconstruct mandibular defects.
Five patients have been treated with mandibular distraction osteogenesis to reconstruct different acquired segmental defects. These mandibular defects (35 to 80 mm in length) were reconstructed by means of internal distraction devices with a transcutaneous activator. All the patients underwent complete resection of the affected bone and immediate placement of the distraction device on the remaining mandible.
The results' analysis was based on clinical observation, postoperative radiographs, histopathologic findings and 3-dimensional computed tomographic scans. Successful distraction osteogenesis was achieved in 3 cases. In 1 case, extensive intraoral exposure of the device was observed, resulting in a failure of the procedure. One patient died of distant metastases 4 months after the resective surgery.
Because of the limited number of cases, this study is preliminary. However, considering the good experimental and clinical results, this new technique offers an alternative for patients with segmental mandibular defects in which, because of local or general reasons, a more aggressive procedure should be avoided.
We examined the expression of bone morphogenetic protein-2 (BMP-2) and proliferating cell nuclear antigen (PCNA) during distraction osteogenesis in the mandible in rabbits. Twenty-four rabbits each had an osteotomy of the left mandibular body, and distraction devices were fixed. The bone was distracted at a rate of 1mm/day for 10 days. Four rabbits were killed at each of 1, 3, 7, 14, and 28 days after completion of distraction, and the mandibles examined radiographically, histologically, and immunohistochemically. Four rabbits that had not been operated on served as controls. Immunohistochemical analysis showed that BMP-2 and PCNA both appeared initially at the edge of the osteogenesis, but tended to disappear after 14 days. After 1, 3, 7, and 14 days after distraction, the ratio of stained cells was significantly higher than in the control group (p<0.05), during the period that active bone formation was shown radiographically and histologically. These results suggest that BMP-2 plays an important part in the induction of bone formation during distraction osteogenesis.
The aim of this study was to indicate the necessity of overcorrection regarding the occurrence of bone height relapse at the end of consolidation period in distracted alveolar bone.
Eleven patients with a total of 17 distractions performed and 43 implants placed were included in this study. Bone height was evaluated on computed tomography before the procedure and on orthopantomographic radiographs following distraction and consolidation. Measurement was performed on the aproximal surfaces of implants and on identical points before and after distraction.
The mean of distraction performed was 6.08 +/- 1.82 mm at mesial points and 6.18 +/- 1.90 mm at distal points of measurement. The mean of bone relapse following consolidation period was 1.57 +/- 1.82 mm at the mesial and 1.79 +/- 1.68 mm at the distal aspects of implants. Statistical evaluation revealed that alveolar bone distraction should include 20% of overcorrection for both mesial and distal points of measurements plus 0.34 mm for mesial and 0.52 mm for distal points of measurement.
Occurrence of relapse found in this study indicates that overcorrection should be included when performing alveolar distraction osteogenesis.
The aim of this study was to evaluate radiographically the effectiveness of alveolar distraction osteogenesis (ADO) technique for vertical reconstruction of atrophy alveolar ridges in partially edentulous patients.
A total of 60 vertical distraction osteogenesis procedures were performed in 55 patients. Two panoramic radiographies were performed in all patients, one the day before the beginning of distraction, and one after consolidation period, 12 weeks postoperatively. The radiographic analysis consisted of obtaining the amount of the vertical bone gain (VBG) in each radiography. For this, we obtained initially the magnification factor (MF) of each panoramic radiography by dividing the real size (RS) of the activation rod among the image size (IS) of the activation rod. After this, to obtain the VGB, we measured initially the length of the distracton preactivation (LD1), which consisted of the distance between the superior portion of the basal plate and the superior portion of the transport plate, multiplying by the MF. Then, we measured the length of the distraction postactivation (LD2), using the same method described before, in radiographies performed 12 weeks postoperatively. The VBG was obtained using the following formula: VBG = LD2 - LD1. The results were applied to descriptive statistical analysis. Complications were also investigated during all of the treatments.
The mean alveolar distraction achieved in 60 cases was 6.27 mm (range, 0 to 10.83 mm). According to the region treated, 51.6% were in the posterior mandible (mean VBG, 4.60 mm), 36.66% were in the anterior maxilla (mean VBG, 7.46 mm), 8.33% were in the anterior mandible (mean VBG, 6.73 mm), and 3.33% were in the posterior maxilla (mean VBG, 6.32 mm). The overall rate of complications that compromised the success of the technique was 8.44%. The increased radiopacity of the distracted region could be observed in the 12-week period after surgery.
The ADO technique was demonstrated to be an effective tool to treat vertical defects of the alveolar ridge with a success rate of 91.66%. Our radiographic analysis seems to be an important tool in verifying the technique as well as planning implant placement after ADO.
A case involving concomitant presentation of a #7 lateral facial cleft with a complete cleft of the ipsilateral lip, alveolus, and palate is presented. The mandibular defect was Pruzansky III with a foreshortened body, absent ramus and absent masseter. Taking advantage of developmental field theory, reconstruction of the osseous defect was undertaken using the autogenous periosteum as a source of mesenchymal stem cells. Expansion of the periosteum was followed by implantation of Helistat (Integra Life Sciences, Plainsboro, NJ) collagen sponge saturated with recombinant human bone morphogenetic protein-2. Stimulation of this distraction-induced envelope by rhBMP-2 resulted in abundant production of bicortical membranous bone in situ within 12 weeks. The neoramus was subsequently suspended from the cranial base, and a temporalis muscle transfer was used to provide motor control of the jaw. Synthesis of bone in this manner is termed DISO (distraction-assisted in situ osteogenesis). The biologic rationale and clinical implications of DISO are discussed.
Distraction osteogenesis is a surgical technique for treating different craniofacial deformities. The sophisticated clinical expression of craniosynosotosis in the face, as well as in the skull can be corrected using different osteotomies, in which we can include the frontal bone, orbits, the malar bones and the maxillae. Once the osteotomy has been completed, we can use the distraction devices to achieve the planned bone advancement. This procedure can be also performed with endoscopic techniques producing less morbidity, with minimal complications, simultaneously producing a highly satisfactory correction of the frontal deformity, the exorbitismus, the malar and the mid-face retrusion in these patients. As the distraction procedure is gradual, soft tissues resistance against the advancement can be easily superated achieving larger antero-posterior bone advancement that can vary between 16 to 32 mm in the frontal area and between 9 to 16 mm in the maxillae. The new position of the bones are maintained in place for new bone formation areas over the osteotomy lines. The aesthetic and functional changes after the procedure have been highly satisfactory in these patients.
This literature review was performed to analyse the outcomes of clinical studies of alveolar distraction osteogenesis (DO) listed by PUBMED between January 1996 and December 2006. A PUBMED search identified 128 articles on alveolar DO. Twenty articles covering 209 cases were analysed, considering location, device and procedural parameters, rate of augmentation, aspect of final implant placement and follow up. The mean latency period was 7.26+/-2.31 days, distraction rate 0.71+/-0.27 mm/day, rate of augmentation 6.88+/-2.52 mm and consolidation period 12.22+/-5.58 weeks. A total of 469 implants were placed and followed post loading for an average of 14.19+/-11.03 months, with a survival rate of 97%. Of the different procedural parameters, only the difference between mean consolidation period for failed (8.10+/-2.51 weeks) and successful (12.43+/-5.62 weeks) implants was statistically significant (P=0.01). Use of DO may be advantageous in terms of the success rate of implants placed in augmented sites, but there is still a lack of sufficient data based on long-term follow up. Future experimental studies should evaluate the application of different methods with a view to shortening the overall treatment period and improving the performance of implants placed in distracted alveolar ridges.
The reconstruction of a maxillary anterior dentoalveolar defect in patients with trauma has been a challenge for surgeons. Extensive loss of bone and teeth in the anterior maxilla presents a complex problem for reconstruction. This is owing to the difficulty in achieving complete closure using overlying soft tissue. Tension-free sutures cannot be used after a large bone graft because the overlying soft tissue on severe bone defects of the anterior maxilla is often deficient and is attached to the underlying atrophic bone by scarring. Distraction osteogenesis provides a method to regain both hard tissue and soft tissue without any grafting. We describe a patient who had severe maxillary anterior bony defects that were restored by means of piezoelectric distraction osteogenesis, followed by dental implant placement. Clinical, radiological, and histological results showed that the reconstruction was successful.
ResearchGate has not been able to resolve any references for this publication.