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Objective. The aim of this retrospective study was to analyze the outcome and complications of alveolar distraction
osteogenesis for the correction of vertically deficient ridges by using intraosseous and extraosseous distractors.
Study design. Seven patients with severely atrophic alveolar crests were treated by distraction osteogenesis in 5
alveolar ridge deficiencies by intraosseous distractors and in 2 alveolar ridge deficiencies by extraosseous distractors.
The bone deficiencies were secondary to atrophy after periodontal disease, tooth extraction, or trauma. Three months
after consolidation of the distracted segments, implants were placed in the distracted areas. The average follow-up
period after prosthetic loading was 50 months.
Results. The mean alveolar height achieved was 7.8 mm (range, 4-9 mm). The intraoperative and postoperative
problems encountered were lack of device activation (n 1), lingual displacement of the distracted segment (n 1),
paresthesia of the lower lip (n 4), and dehiscence and plate exposure (n 2). Most of these complications were
considered to be minor complications and were solved without any problems.
Conclusion. It was concluded that alveolar distraction osteogenesis seems to be an effective technique to treat vertical
alveolar ridge deficiencies, but adequate treatment planning is necessary for success. The complications related to this
technique can be solved with simple treatments. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e7-e13)
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Gnbay et al.
Age
Gender
Distraction zone
Type of distractor
Etiologic factor
No. of distractors
1
2
3
4
5
6
7
38
26
30
64
24
53
48
M
F
F
F
F
F
F
Mandibula premolar
Mandibula premolar
Maxilla anterior
Mandibula anterior
Mandibula premolar-molar
Mandibula molar
Mandibula anterior
Lead System
Lead System
Lead System
Modus
Lead System
Lead System
Modus
Gun shot
Hypodontia
Traffic accident
Edentulous
Alveolar resorption
Alveolar resorption
Edentulous
1
1
2
1
1
1
1
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Gnbay et al. e9
Fig. 1. A, Panoramic radiograph of 30-year-old patient after mandibular fracture and traumatic avulsion of the anterior teeth and
alveolar bone. B, Placement of the alveolar distractor during surgery. C, Panoramic radiograph after lengthening of the alveolar
bone. D, After removal of the device and 4 implant placements. E, Panoramic radiograph 3.5 years after final prosthetic
rehabilitation.
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Fig. 2. A, Panoramic radiograph of 48-year-old patient with severely resorbed mandible. B, Intraoral photograph showing
mandibular atrophy. C, Segmental alveolar osteotomy of the anterior region with extraosseous alveolar distractor. D, Postdistraction panoramic radiograph showed lengthening of the alveolar bone. E, Panoramic radiograph 1.5 years after final prosthetic
rehabilitation.
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Volume 105, Number 5
Table II. Gained bone amount, transport width, number of implants, and type of prosthesis in the distracted
area
Case
no.
Distraction
(mm)
Transport
wdth
No. of
implants
Type of prosthesis
1
2
3
4
5
6
7
4
9
8
9
9
8
8
23
13
42
34
25
29
15
3
4
3
2
2
Precision attachment
Fixed partial denture
Fixed partial denture
Complete denture
Fixed partial denture
Fixed partial denture
Ball attachment
Alveolar distraction should be avoided in a very atrophic mandible, where a complete bone fracture may
occur. Fracture of the mandible is the most severe
complication encountered.26,29,30 In the present study,
patients whose mandibular bone was at least 9-10 mm
vertically were for these reasons preferred. Fracture of
the transport segment and mandible during surgery was
not observed.
Difficulties were encountered in completing the osteotomy on the lingual side, which we had to access
from the labial vestibular side. To do this, some authors
have constructed fine chisels from cement spatulas
which were carefully introduced from the vestibular
side, checking their exit from the lingual side with a
finger to avoid damage to the lingual mucoperiosteum
or the floor of the mouth, but the ultrasonic osteotome
has proven to be much more comfortable, without the
risk of damage to the vascular plexa of the floor of the
mouth.19
A common problem with the Lead System is the difficulty of controlling the direction of the device to keep the
vector straight.16,19,24 Inappropriate direction of distraction may be caused by any of several factors, including
resistance of the soft tissue on the lingual/palatal side of
the muscles and intact periosteum.19 The distractor will
tend to lean to the lingual side, requiring postoperative
repositioning. Careful preoperative planning is essential to
ensure good vectorization.33 Repositioning of a displaced
transport segment is generally performed using orthodontic appliance arch wires.16-20,34 In 1 patient the displaced
segment was repositioned with orthodontic device. It has
been reported that extraosseous distractors maintained
much more stabilization at basal and transport segments
than intraosseous distractors.35 In the present study, we
did not notice malposition of the transported segments at
extraosseous distractors. We think that malposition and
stabilization problems that were seen in intraosseous distractor were related to lack of stabilization in that type of
distractor. When the transport segment is relatively long
(more than about 2 cm), it may be difficult to achieve
accurately controlled osteogenesis using a single distractor. The use of 2 distractors, one at each end of the
transport segment, resolves this problem.19,20,24,36 For this
reason, we applied 2 distractors in a wide maxillary defect
in case 3.
Temporary paresthesias showed spontaneous resolution within 6-8 weeks with conservative treatment, similar to other studies,31,37 in our 4 patients. The use of an
ultrasonic osteotome might decrease the risk of nerve
damage during osteotomy preparation.31
The activation period of the distraction device is
usually pain-free38; however, we noted tension-related
pain in 1 patient because of more than 1 cm of alveolar
distraction. The pain disappeared when the rate of
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Gnbay et al.
Table III. Minor and major complications in alveolar distraction osteogenesis with necessary treatments
Case no.
Major complications
Minor complications
Treatment
1
2
3
4
5
6
Local
Repositioned with orthodontic devices
Local
Local
Local
Reduction of distraction rate
Local
distraction was reduced to 0.25 mm/24 h. It is suggested to increase the frequency of elevation without
changing the daily rate.37 Parallel or convergent lateral
osteotomies during activation may result, with discomfort, friction, and possible compromise of the final
outcome. Applying lateral osteotomies divergent to one
another during surgery is recommended.26 We made
trapezoidal osteotomies in operations for facilitation of
the transport segment movement. Saulacic et al.31 mentioned that the varying amount of distraction performed
in patients reporting pain in their clinical study indicated that the occurrence might be subjective. We agree
with these authors, because the statement of our patient
about pain may be doubtful.
Soft tissue dehiscence was the most common minor
complication (37.8% of distraction sites) with 6.7% of
these becoming infected in a recent study. One of the
causes for this may well be the distraction rate of 0.9 mm
per day.30 Dehiscence and plate exposure were found in 2
of the present cases, but did not affect the functional or
esthetic results. We recommended daily rinsing of the area
with chlorohexidine mouthrinse for treatment.
In other published studies, the prevalence of complications that compromised the final outcome is 2.7% to
20%.18,26,30,38 It was concluded in a clinical study that
ADO is an effective technique to treat vertical alveolar
ridge deficiencies.29 Most complications related to surgery
can be avoided with adequate treatment planning.26 In
other clinical studies the authors reported that most of the
minor complications could be readily resolved by the use
of appropriate procedures, but very close follow-up is
required.19,20,29 Vertical alveolar distraction osteogenesis
is not an uncomplicated procedure; however, long-term
survival of dental implants inserted into distracted areas is
satisfactory.30 On the other hand, Enislidis et al.39 reported that the use of subperiosteal devices for vertical
augmentation of edentulous mandibles is hazardous and
offers no advantage over other surgical methods and that
all of the patients had severe complications. Fukuda et
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Reprint requests:
Dr. Banu zveri Koyuncu
Department of Oral and Maxillofacial Surgery
Ege University
Bornova
Turkey
banuozverikoyuncu@yahoo.com