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Indian Journal of Dentistry 2012 Volume -, Number -; pp. 1e4

Review Article

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Distraction osteogenesis e An overview of principle and its applications

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Vinu Thomas Georgea,*, Veena Hegdeb

ABSTRACT
Distraction osteogenesis is a surgical process for reconstruction of skeletal deformities and augmentation procedures. It involves gradual, controlled displacement of surgically created fractures which result in simultaneous expansion of soft tissue and bone volume. Although the majority of surgical experience with distraction technology has been in orthopedics, early results indicate the process to be equally effective in facial skeletal reconstruction. It is now possible to apply distraction technology to deformities of the jaws and dento-alveolar process. Development of miniature, internal distraction devices has made this clinically feasible and practical with a wide variety of application in various elds of restorative dentistry, implant dentistry and maxillo-facial prostheses. Key messages: Distraction osteogenesis is dened as a biologic process of new bone formation between the surfaces of bone segments that are gradually separated by incremental traction. Keywords: Implant distractors, Osteogenesis, Histogenesis

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INTRODUCTION
Correction of deformities associated with deciencies in maxilla and mandible using osteotomies may not yield the desired result. When large skeletal movements are required, the associated soft tissue often cannot adapt to the acute changes and stretching due to the surgical repositioning of bony segments. The failure of tissue adaptation results in surgical relapse, excessive loading of TMJ and neuro sensory loss as a result of stretching of nerves. In some cases the amount of movement is so large that the gap created require bone grafts harvested from secondary surgical sites such as iliac crest.

PRINCIPLE
DO involves an osteotomy to separate segments of bone and application of an appliance that will facilitate the gradual and incremental separation of bone segments. The gradual tension placed on the distracting bony interface produces continuous bone formation. The surrounding tissue appears to adapt to this gradual tension, producing adaptive changes in all surrounding tissues such as muscles and tendons, nerves, cartilage, blood vessels and skin. Because the adaptation involves a variety of tissue types in addition to bone it includes distraction histogenesis.2

HISTORY DEFINITION
Distraction osteogenesis is dened as a biologic process of new bone formation between the surfaces of bone segments that are gradually separated by incremental traction.1 Use of traction techniques to help bones heal to a correct length can be traced back to the time of Hippocrates. An external device was used to apply traction to a fractured and shortened leg. Bone lengthening was rst attempted

Associate Professor, bProfessor, Department of Prosthodontics and Crown & Bridge, Manipal College of Dental Sciences, Manipal, Karnataka 576104, India. * Corresponding author. Tel.: 91 8105306736 (mobile), email: drvgeorge@gmail.com Received: 1.9.2011; Accepted: 14.8.2012 2012 Indian Journal of Dentistry. All rights reserved.
http://dx.doi.org/10.1016/j.ijd.2012.08.001

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Please cite this article in press as: George VT, Hegde V, Distraction osteogenesis e An overview of principle and its applications, Indian Journal of Dentistry (2012), http://dx.doi.org/10.1016/j.ijd.2012.08.001

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in the early 1900s when Codivilla performed osteotomies and stretched femur bones. Gavriel Ilizarov, a Russian surgeon developed the current concept in 1950. He invented the armamentarium for the technique. The technique gained popularity in 70s and 80s. Since then the application of these principles has extended to all forms of orthopedic correction, including craniofacial surgery. McCarthy et al rst reported distraction osteogenesis for correction of mandibular deformity in hemi-facial microsomia in 1992.3

REVIEW OF LITERATURE
In1996, Chin and Toth reported the rst clinical application of vertical mandibular alveolar distraction osteogenesis. They reported that the regenerated bone withstands the functional demands of implant loading, and survival rates of implants placed in distracted areas are consistent with those of implants placed in native bone. Celar et al (2002) reported correction of infra positioned osseointegrated implants in an adolescent female with ectodermal dysplasia and oligodontia with the technique.4 Paul C Armbruster et al (2004) stated that the technique can be applied to rehabilitate acquired palatal defects. Distraction osteogenesis was used to narrow the defect to facilitate bone and soft tissue closure.5 Chiapasco M et al (2004) undertook a multicenter study to evaluate the use of vertical distraction osteogenesis in the correction of vertically decient alveolar ridges and to evaluate whether the vertical bone gained by distraction osteogenesis was maintained over time when dental implants were placed in the distracted areas. The results of this study demonstrated that the technique is reliable for the correction of vertically decient edentulous ridges. The regenerated bone appeared to withstand the functional demands of implant loading.6 Perry M et al (2005) compared bone-to-implant contact (BIC) in alveolar bone augmented by distraction osteogenesis with that of onlay iliac crest grafting. The data showed that both distraction osteogenesis and onlay grafting produce sufcient bone for implant placement.7 Cecilia E Aragon and Richard N Bohay (2005) evaluated the technique for alveolar augmentation prior to prosthodontic rehabilitation.8 Selim Erkut and Sina Uckan (2006) described the use of alveolar distraction osteogenesis to promote the formation of new bone and soft tissue in a large, severely resorbed segment of maxillary alveolus to achieve esthetic and functional restoration.9 Won-Suck Oh et al (2006) described prosthodontic management of a young girl treated for leukemia who has undergone bilateral maxillectomy secondary to mucormycosis to restore speech, deglutition, mastication and respiration. Distraction osteogenesis,

bone grafts, osseo-integrated implants and magnet attachments were used to provide retention, support and stability of a large denitive obturator.10 Iida S et al (2006) presented a procedure involving 2-stage alveolar distraction osteogenesis using eccentric distraction devices for the augmentation of resorbed transplanted iliac bone following mandibular tumor resection. A 6-month consolidation period was allowed between the rst and second distractions, and endosseous implants were placed 4 months after the second distraction. Computerized tomographic images obtained before the implantation revealed that, 10 months after the rst distraction, the bone generated still showed lower density compared with the basal bone, but the bone from both distractions showed enough maturity for implantation. This shows that 2-stage alveolar distraction osteogenesis can be a useful and safe procedure for excessive alveolar lengthening if a sufciently long consolidation period is allowed.11 William E Dinse et al (2008) in their clinical report described the use of distraction osteogenesis and a xed implant-supported prosthesis to treat a premaxillary defect.1 Raghoebar GM et al (2008) assessed the treatment outcome (implant survival, surgical complications, patient satisfaction) of vertical distraction of the severely resorbed edentulous mandible. Vertical distraction of the anterior segment of a severely resorbed alveolar ridge of the mandible can provide a proper basis for insertion and osseointegration of endosseous load-bearing implants with good implant survival, few surgical complications, and good patient satisfaction.12 Mallika Kalle et al (2009) presented a case report of a successful alternative approach prior to prosthodontic rehabilitation of a patient with poor and resorbed mandibular ridges, using alveolar distraction osteogenesis as a preprosthetic procedure and further discusses the merits and demerits of this novel procedure when considering implant placement.13

PHASES OF DISTRACTION
Osteotomy or surgical phase Latency period - Distraction phase - Consolidation phase - Appliance removal - Remodeling period During the surgical phase osteotomy is performed and the distraction appliance is secured in place. The latency phase involves early stages of bone healing at the osteotomy bony interface. Usually the appliance is not activated for 7 days. Distraction phase begins at a rate of 1 mm per day i.e., 0.5 mm twice each day. Rate of distraction is the amount of activation per day. Below 0.5 mm per day
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Please cite this article in press as: George VT, Hegde V, Distraction osteogenesis e An overview of principle and its applications, Indian Journal of Dentistry (2012), http://dx.doi.org/10.1016/j.ijd.2012.08.001

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Distraction osteogenesis

Review Article

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may lead to premature union and above 1.5 mm per day may lead to non-union. Rhythm is the timing of appliance activation each day. Regenerate is the new immature bone that is formed. Mineralization of the regenerate bone takes place during the consolidation phase. The appliance still remains in place. Then appliance is removed followed by remodeling which is the period from the application of normal functional loads to the complete maturation of the bone.

For ridge augmentation prior to rehabilitation with implant retained dentures For augmentation of resorbed alveolar ridges to improve the stability of mandibular dentures For augmenting the bones to improve the retention of maxillofacial prostheses For favorable positioning of retentive components of implant retained maxillofacial prostheses.

CONFLICTS OF INTEREST COMPONENTS OF DISTRACTED ZONE

All authors have none to declare.
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Radiolucent central zone comprising of brous tissue. Bone formation along the stretched brous tissue. Remodeling area where bone spicules are lined by osteoblasts and osteoclasts. Area of mature bone which remodels in a year or so.14

REFERENCES
1. Dinse William E, Burnett Robert R. Anterior maxillary restoration using distraction osteogenesis and implants: a clinical report. J Prosthet Dent. 2008;100:250e253. 2. James R Hupp, Edward Ellis III, Myron R Tucker. Correction of dentofacial deformities. In. Contemporary oral and maxillofacial surgery. 3. Krishna R, Kumar S, Singh AK, Bhatnagar SK, Kumar V. The use of distraction osteogenesis for treatment of the mandibular deformity in hemi facial microsomia: a case report of the double osteotomy technique. Indian J Plast Surg. 2001;34: 75e77. 4. Celar G, Durstberger Gerlinde, Zauza Konstantin. Use of an individual traction prosthesis and distraction osteogenesis to reposition osseointegrated implants in a juvenile with ectodermal dysplasia: a clinical report. J Prosthet Dent. 2002;87:145e148. 5. Armbruster Paul C, Grossmann Yoav, Shannon Michael, Finger Israel M, Walters Paul. A multidisciplinary approach to restoring an acquired palatal defect using distraction osteogenesis: a clinical report. J Prosthet Dent. 2004;92: 316e321. 6. Chiapasco M, Consolo U, Bianchi A, Ronchi P. Alveolar distraction osteogenesis for the correction of vertically decient edentulous ridges: a multicenter prospective study on humans. Int J Oral Maxillofac Implants. 2004;19:399e407. 7. Perry M, Hodges N, Hallmon DW, Rees T, Opperman LA. Distraction osteogenesis versus autogenous onlay grafting. Part I: outcome of implant integration. Int J Oral Maxillofac Implants. 2005;20:695e702. 8. Aragon Cecilia E, Bohay Richard N. The application of alveolar distraction osteogenesis following nonresorbable hydroxyapatite grafting in the anterior maxilla: a clinical report. J Prosthet Dent. 2005;93:518e521. 9. Erkut Selim, Uckan Sina. Alveolar distraction osteogenesis and implant placement in a severely resorbed maxilla: a clinical report. J Prosthet Dent. 2006;95:340e343.

ADVANTAGES
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Ability to produce larger skeletal movements Elimination of the need for bone grafts (secondary surgical site) Better long-term stability Less trauma to TMJ Decreased neuro-sensory loss

DISADVANTAGES
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Placement and positioning of the appliance to produce the desired vector of bone movement is technique sensitive sometimes results in less than ideal occlusal positioning, resulting in discrepancies such as small open bites or asymmetries. Two procedures: placement and removal of the distractors. Increased cost, longer Rx time, patient compliance & frequent appointments.

APPLICATIONS OF DISTRACTION OSTEOGENESIS

For the correction of e - Mandibular hypoplasia & asymmetries - Hemi-facial microsomia - Maxillary arch width discrepancies - Skull deformities - Mid-face deciencies - Dento-alveolar discrepancies

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10. Oh Won-Suck, Roumanas Eleni. Dental implant-assisted prosthetic rehabilitation of a patient with bilateral maxillectomy defect secondary to mucormycosis. J Prosthet Dent. 2006;96:88e95. 11. Iida S, Nakano T, Amano K, Kogo M. Repeated distraction osteogenesis for excessive vertical alveolar augmentation: a case report. Int J Oral Maxillofac Implants. 2006;21:471e475. 12. Raghoebar GM, Stellingsma K, Meijer HJ, Vissink A. Vertical distraction of the severely resorbed edentulous

mandible: an assessment of the treatment outcome. Int J Oral Maxillofac Implants. 2008;23:299e307. 13. Kalle Mallika, Karthik MS, Hegde Chethan, Shetty Sridhar N, Raghotham Kavitha. Enhancement of support for mandibular complete denture prosthesis: a preprosthetic ridge augmentation procedure by distraction osteogenesis. J Indian Prosthodont Soc. 2009;9:88e91. 14. Srinivsan B. Orthodontic surgery. In: Textbook of Oral and Maxillofacial Surgery. 2nd ed.

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Please cite this article in press as: George VT, Hegde V, Distraction osteogenesis e An overview of principle and its applications, Indian Journal of Dentistry (2012), http://dx.doi.org/10.1016/j.ijd.2012.08.001