Distraction osteogenesis for

vertical bone augmentation prior

to oral implant reconstruction
Bradley S. McAllister & Thomas E. Gaffaney
Distraction osteogenesis has been employed in the
lengthening of long bones for the last 100 years (8).
During the last 50 years, predictable results having
been developed through scientic studies by the
Russian surgeon, Gavriel Ilizarov (1619). The basic
principle developed by Ilizarov has the following
three distinct phases:
a latency phase of approximately 7 days of initial
post surgical healing;
the distraction phase, consisting of the gradual
incremental separation of two bone pieces at a rate
of approximately 1 mm per day;
consolidation phase, during which new bone forms
in the regenerate zone between the separated bone
pieces.
Over the last 7 years the technique of distraction
osteogenesis has been under development for verti-
cal augmentation of the mandible and maxilla prior
to implant reconstruction (6). With such a short his-
tory of employing alveolar distraction for the specic
application of implant reconstruction, the technique
is clearly still in its infancy. Yet, one must not lose
track of the fact that the general principle of distrac-
tion osteogenesis has been extensively investigated
and successfully applied to a variety of bone pro-
blems over the last century.
While no controlled long-termstudies exist with any
of the commercially available alveolar bone devices
available today, excellent case reports and animal stu-
dies exist for the distraction devices currently avail-
able. These publications demonstrate the potential for
successful results with a variety of intraosseous and
extraosseous distractors. The rst published case
report of alveolar bone distraction was that of a single
mandibular case using an intraosseous distractor with
a threaded rod, a threaded transport plate and a sta-
bilizing unthreaded base plate (6). Additional case
reports have been published over the past few years
with intraosseous, extraosseous and implant distrac-
tors (4, 10, 15, 21, 24, 34). Recently, a case history
review of prosthetically restored distraction cases,
loaded for a minimum of 3 years, revealed a success
rate of 90.4% for the 84 implants placed in distracted
bone utilizing devices that are not commercially avail-
able (20). This high rate of success compares favorably
with other reports evaluating rates of oral implant
success in regenerated bone (14).
Several animal studies have been published demon-
strating successful vertical augmentation. Customized
ossseointegrated implant supported distraction dev-
ices were utilized in dog mandibles to gain 9 mm of
vertical augmentation. The regeneratedbone was eval-
uated histologically (2, 3). The distraction gap, or
regenerate zone, was lled with new bone and both
a lingual and buccal cortex were formed. The crestal
bone levels did not change during a year of implant
loading (3). Additional dog studies by Oda and collea-
gues have evaluated botha two-stage andsingle-phase
approach to implant placement (27, 28). In the single
stage approach, implants were used as the distraction
device and left to integrate (27). While the regenerated
bone in the distraction gap was found to consist of a
comparable percent of bone area, 20% of the implants
failed to integrate, minimizing the clinical validity of
this approach. Their more successful two-stage
approach utilized a simple intraosseous screw for
active distraction. Implants were placed during the
consolidation phase and evaluated at 12 weeks. Less
than 1 mm of crestal loss was found and minimal
differences were noted between the transport segment
and the regenerated bone for both percent bone area
and percent bone-to-implant contact.
54
Periodontology 2000, Vol. 33, 2003, 5466 Copyright
#
Blackwell Munksgaard 2003
Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
Studies using in vitro techniques to gain a better
understanding of the phenomenon of distraction
osteogenesis have evaluated how osteoblasts respond
to mechanical stimulation. Elevations ingrowthfactor
and cytokine gene expression have been demonstra-
ted in response to the mechanical stimulation in vitro
(7). Together with the extensive animal studies in long
bones and the numerous craniofacial applications
(25, 32), the principle of distraction osteogenesis is
now a part of the periodontist's armamentarium for
implant placement.
Surgical technique of distraction
osteogenesis
Proper treatment planning is imperative for distrac-
tion osteogenesis. Typically, for distraction to be
considered, a minimum of 67 mm of bone height
must remain above vital anatomic structures and at
least a 4 mm vertical defect of sufcient length
(edentulous zone of three or more missing teeth)
must exist when measuring from the height of the
adjacent bony walls to the vertical depth of the oss-
eous defect. In the event teeth adjacent to the eden-
tulous region being considered for distraction show
considerable marginal bone loss, it is reasonable to
consider extraction and extension of the edentulous
zone to create a true vertical defect of at least 4 mm
depth. With no evidence existing that the attachment
level on teeth can be improved through distraction, it
may be necessary to sacrice a compromised tooth
to optimize the amount of vertical bone improve-
ment. In fact, in animal studies, attempts to improve
the attachment level on natural teeth with distraction
were unsuccessful (1). Small vertical defects of only
one or two teeth tend to have a higher rate of com-
plication when distracted and should usually be trea-
ted with conventional bone grafting techniques (20).
While it is desirable to perform distraction under
conscious sedation or general anesthesia, it is possi-
ble to perform the surgical procedure using only
regional anesthesia. Either a vestibular mucosal inci-
sion or a mid-crestal incision placed at the buccal
line angle staying in gingival (keratinized) tissue may
be successfully utilized to access the bone (22, 24). A
full thickness ap is elevated on the buccal aspect
only, taking care not to reect the tissues on the
alveolar crest or towards the lingual. The horizontal
and vertical osteotomies are prepared with either a
ssure bur, or a saw, taking great care not to damage
the lingual periosteum. The specic order of distrac-
tor placement, distractor xation and nal osteot-
omy preparation is specic to the system being
used. Once the distractor is placed and the osteo-
tomies are complete, device function is tested to
make sure that there are no interferences. If the ver-
tical osteotomies slightly converge to the coronal,
and to the lingual aspect, there will be little risk for
interference problems. Suturing can be easily accom-
plished by primary closure using a slowly resorbing
suture material such as vicryl.
A 1-week latency healing period should be
employed prior to initiation of distraction. In young
patients with rapid healing, a shorter period may be
utilized. In older patients, or those with slow soft
tissue healing, a slightly longer latency period may
be utilized. With complete soft tissue closure, dis-
traction may be initiated at a rate of up to 1 mm
per day. A slower rate of distraction may be utilized
in older individuals and in cases of dense bone with
minimal vascularity. It is important to optimize the
incremental traction for proper tension stress and
ultimate osseous healing. While continuous distrac-
tion, or incremental movement over multiple daily
advancements, has been shown to improve the bone
regeneration it is not clear what the optimal rate and
frequency is for alveolar distraction (16, 19, 30). A
reasonable approach for alveolar distraction would
be to have the patient turn the device three times
daily for incremental advancements of 0.25 to
0.33 mm. Optimal bone formation was found to
occur at physiologic levels of 2,000 microstrain with
some decreases in hydroxyapatite crystal formation
by 20,000 microstrain/one cycle per day. Only
brous tissue was formed in specimens distracted
with the hyperphysiologic levels of 200,000 and
300,000 microstrain, indicating the importance of
not placing excessive tension on the tissues (26).
Meyer et al. (26) also demonstrated that peak strain
magnitudes rather than frequency inuence the
bone cell differentiation and matrix production, indi-
cating smaller more physiologic advances, even if
frequent, will likely optimize the bone regeneration.
While some slight crestal resorption is often found
during consolidation, it usually is no further apical
than the adjacent bone levels. Therefore, it may be
benecial to overdistract by 23 mm. Any further
overcorrection may minimize the potential for
bone-to-bone contact between the vertical osteo-
tomies and the transport segment resulting in a
higher incidence of non-union or incomplete dis-
traction gap ossication.
Distractor removal and implant placement will be
performed during the consolidation phase. It is pos-
sible to place implants at the time of distractor
Distraction osteogenesis
55
removal, or it may be benecial to delay placement
until further hard and soft tissue consolidation has
occurred. The decision should not only be based on
how the area is healing, as determined clinically and
radiographically, but also on the position of the pro-
posed implant. In partially edentulous cases the
implant treatment plan typically consists of placing
implants in the locations of the vertical osteotomies,
indicating the need to have adequate consolidation
to prevent segment mobilization during implant
osteotomy preparation, or actual implant placement.
In a signicant number of distraction cases supple-
mental bone and soft tissue grafting may be required
to optimize the nal result (20, 23, 24). As a minimum
timeline for consolidation, the long bone literature
has suggested 5 days per 1 mm of distraction (29).
Standard integration periods consistent with newly
regenerated bone should be employed prior to pros-
thetic loading of the dental implants placed in dis-
tracted bone.
ACE surgical distractor
The intraosseous ACE distractor (ACE Surgical Sup-
ply, Brockton, MA) is made of titanium alloy and has
three main components during active distraction
(Fig. 1). The distractor body engages the bony trans-
port segment with external threads that are of the
same pattern as that of a conventional 3.75 mm oral
implant. The distractor body comes in both a 5 mm
thread length (long body) and a 3 mm thread length
(short body). Unless anatomic constraints exist, it is
advisable to utilize the long body distractor for max-
imal xation. The axial distraction screw is threaded
through the distractor body and used for active dis-
traction. The base plug has an internally threaded
hole in which the axial distraction screw sits and
engages for the distraction process. As the axial dis-
tractor screw is turned in a clockwise direction
(2.5 turns/1 mm), the upper distractor body with
the bony transport segment advances in a coronal
direction away from the intact bony bed with the
stationary base plug. This distraction system has a
very simple removal procedure that does not require
mucoperiosteal ap reection unless implants are
placed at the time of the distractor removal surgery.
At distractor removal the base plug is easily removed
by threading the base plug removal tool onto the
internal threads of the base plug. Reports to date with
this system have shown favorable results (21, 24, 34).
The following examples illustrate the capabilities
of this intraosseous distractor. A 42-year-old male
presented for oral implant reconstruction following
a motor vehicle accident. A signicant vertical defect
was present in the area of missing teeth 32 through
41 (Fig. 2). After horizontal osteotomy preparation,
the distractor was placed. Once distractor stability
was conrmed, vertical osteotomies were completed
utilizing a straight ssure bur (Fig. 3). After a 1-week
latency period, distraction was initiated at the rate of
1 mm/day for 8 days utilizing guidance components
Fig. 1. ACE distractor components during activation. The
axial distraction screw is shown during activation with the
0.88 mm hex driver. A long body distractor with an axial
distraction screw and base plug is shown.
56
McAllister & Gaffaney
and an appropriate temporary (Fig. 4). Without
mucoperiosteal ap reection the distractor was
removed after 2 months of consolidation. After a
total of 4.5 months of consolidation two implants
were placed and a biopsy was taken from the regen-
eration zone (Figs 5 and 6). After a standard integra-
tion period the implants were restored and loaded.
Fig. 2. Radiographic view of the vertical bone loss.
Fig. 3. The segment after placement of the distractor and
completion of both the horizontal and vertical osteotomies
to mobilize the segment.
Fig. 4. Radiographic view at the completion of approxi-
mately 8 mm of distraction.
Fig. 5. Two 18-mm implants have been placed and a
biopsy was taken from the regeneration zone.
57
Distraction osteogenesis
Radiographic and clinical evaluation after 3 years
shows excellent preservation of bone and soft tissues
(Fig. 7). A 36-year-old female presented with teeth 32
through 43 lost from untreated aggressive periodon-
titis. The 6 mm vertical defect that remained (Fig. 8)
was treated with two distractors (Fig. 9). For this
system, one distractor is typically placed for every
three missing teeth up to a maximum of three dis-
tractors. Following 2 months of consolidation, imp-
lants were placed at the time of distractor removal
and allowed to heal for 7 months prior to nal
restoration (Fig. 10a,b).
As with most distraction systems, it is imperative
that the guidance components and a suitable
Fig. 6. Regeneration zone biopsy. (a) The entire histologic
specimen (original magnication 3). (b) Magnied view
of an area containing immature woven bone (original
magnication 40). (c) Magnied view of an area contain-
ing more mature lamellar bone (original magnication
40) (Stevenel's blue Van Gieson's picric fuchsin stain).
Fig. 7. The radiographic view of the distraction case after
3 years.
Fig. 8. Surgical view after the reection of only the buccal
mucoperiosteal ap prior to the placement of two ACE
distractors.
58
McAllister & Gaffaney
temporary be utilized to insure proper transport seg-
ment positioning. Base plug instability may arise
during placement of the ACE distractor, especially
if an insufcient amount of bone remains apical to
the base plug. Due to the dense inferior cortex of
the mandible, planned vertical distraction can be
achieved even with complete disattachment of the
base plug. Currently, the preassembled device con-
tains both the base plug and the distractor body, so
instability is not likely to occur. Radiographic con-
rmation at the completion of surgery and during
distraction is advised to conrm proper positioning
of the distractor components.
The Leibinger Endosseous Alveolar
Distraction (LEAD) system
The intraosseous LEAD system (Stryker Leibinger,
Kalamazoo, MI) consists of a 2 mmdiameter threaded
rod, a threaded transport plate, and a stabilizing
unthreaded base plate (Fig. 11). The threaded distrac-
tionrodcomes in17, 22 and32 mmlengths andcanbe
advanced0.4 mmper turn. The angle of the osteotomy
preparation for the threaded rod should be consistent
with the proposed vector of distraction. The transport
plate and base plate are then bent and xed into place
with xation screws to maintain the proposed vector
(Fig. 12). With the signicant forces from the palatal
tissues and lingual musculature it is advisable to use a
guidance temporary toensure the transport segment is
Fig. 9. Radiographic view at the completion of approxi-
mately 8 mm of distraction with 2 mm of overcorrection.
The guidance axial distraction screwis engaging the ortho-
dontic band retained lingual arch wire xed/removable
temporary.
Fig. 10. The nal restoration after consolidation (a, b).
59
Distraction osteogenesis
orientated correctly with this system (Figs 13 and 14).
With the narrownature of the threaded rod it is impor-
tant not to apply too much horizontal force as bone
resorption can occur and the rod may become dis-
placed from the transport segment. With the narrow
threaded rod a vestibular incision can be made and
drilling the threaded rod osteotomy can be made with-
out mucoperiosteal ap reection even in cases with
narrow ridges. It is, however, still necessary to later
augment the ridge in the horizontal direction if it has
not been completed prior to distractor placement.
Reports to date with this systemhave shown favorable
results (6, 12, 13).
KLS Martin distractor
The extraosseous Track distractors (KLS Martin, Jack-
sonville, FL) are made of titanium with microplates
that have been welded onto the sliding mechanism of
the actual distraction screw (Fig. 15). Multiple sizes
are available depending on the regenerative needs.
For full arches the Track 1.5 is indicated and for very
small segments the Track 1.0 microdistractor may be
utilized. For most partially edentulous distraction
patients the Track Plus distractor is indicated,
because it has the most rigidity due to the apical
extension and it is still of manageable size.
Fig. 11. The LEAD system showing the threaded rod, sta-
bilizing base plate and threaded transport plate.
Fig. 12. The LEAD system xated in place after the com-
pletion of the horizontal and vertical osteotomies.
Fig. 13. The ridge as seen prior to the start of distraction.
Fig. 14. After the completion of distraction the coronal
advancement of the transport segment can be appreciated.
60
McAllister & Gaffaney
The following case study demonstrates how this
extraosseous distractor functions. A 41-year-old male
presented following untreated trauma that fractured
teeth 11 and 21. Secondarily this resulted in 75%
bone loss on the mesial and facial aspects of tooth
12 (Fig. 16). The patient was a smoker, but had no
other medical issues. All three hopeless teeth were
extracted. A graft of anorganic bone (Bio-Oss, Osteo-
health, Shirley, NY) was placed and the area was
allowed to heal for 5 months. After a vestibular inci-
sion was made, a Track Plus device was modied to
t the bony topography of the area and screwed to
place. The locations for vertical and horizontal osteo-
tomies were marked, the device removed, the osteo-
tomies completed with saws and the device was
replaced with additional xation screws (Fig. 17).
After a 1-week latency healing period, distraction
was initiated at a rate of approximately 1 mm/day
(1 turn for 0.3 mm). Concurrent with completion of
distraction, excellent vertical height was obtained
(Fig. 18). However, some soft tissue dehiscence of
the distraction device was noted at the end of the
consolidation period (Fig. 19). With extraosseous
devices, soft tissue complications may occur more
frequently due to the compromised blood supply, yet
this does not appear to affect the osseous outcome as
long as soft tissue grafting is completed at the time of
distractor removal. After 5 months of consolidation,
the distractor was removed, a soft tissue graft was
added, and implants placed (Fig. 20). After 4 months
of further healing, a provisional implant supported
restoration was placed (Fig. 21).
Fig. 15. The KLS distractors: (a) Track 1.5, (b) Track Plus
and (c) Track 1.0.
Fig. 15. continued
61
Distraction osteogenesis
With the extraosseous distractors there is no
bone width requirement; however, ultimate implant
reconstruction requires a 57-mm-wide ridge. Thus,
grafting with autogenous bone to achieve the neces-
sary width may be necessary prior to distraction. A
split ridge approach for increasing the ridge width is
the suggested approach prior to distraction (9, 31).
While the potential for nerve injury exists for any
posterior mandible distraction case, the extraosseous
design is the best suited for this region (Fig. 22). An
insufcient number of patients have been treated for
a predictive incidence of nerve damage from the
distraction osteotomies in this area to be deter-
mined. The small number of surgeries performed
in this area is likely due to the limited number of
indications for distraction in this area. A minimum of
56 mm bone is required superior to the nerve to
allow for clearance with the nerve during horizontal
osteotomy preparation and to maintain a transport
segment height of 34 mm. For any amount less
than this 56 mm, nerve repositioning should be
Fig. 16. Initial radiographic appearance showing exten-
sive evidence of bone loss on teeth 12, 11 and 21.
Fig. 17. The KLS Martin Track Plus fully xated with
completed vertical and horizontal osteotomies prior to
suturing.
Fig. 18. Radiographic appearance at the completion of
6 mm of distraction.
Fig. 19. At the end of the consolidation phase, excellent
vertical height can be appreciated.
62
McAllister & Gaffaney
considered, or no implant placement and use of an
alternative prosthetic replacement. Considering that
when 8 mm of bone height is present above the
nerve 10 mm implants can usually be placed with
minimal particulate vertical guided bone regenera-
tion. Therefore only those cases with 57 mm of
bone superior to the nerve should be considered
for distraction, leaving a fairly small number of actual
cases. Reports to date with this extraosseous system
have shown favorable results (4, 15).
Distractor and oral implant
combination devices
The concept of a prosthetically restorable distractor
(Fig. 23) was introduced by SIS Trade Systems (Kla-
genfurt, Austria). A histologic study in sheep has
demonstrated that this distractor becomes osseoin-
tegrated and can therefore function as a loaded oral
implant (11). A study in 35 patients evaluating these
distraction implants found a range of 46 mm
increase in vertical height and no complications in
29 of the 35 patients (10). Conceptually, this
approach is clearly superior because the secondary
surgeries for distractor removal and implant place-
ment are eliminated. There are, however, several
major complications of concern that could arise spe-
cic to this approach, including a lack of device
osseointegration, improper device orientation for
restoration, crestal bone loss during distraction
exposing the rough coronal device threads, and the
inability to initially place the devices in ideal pros-
thetic position due to the interference of the
vertical osteotomies. The Veriplant distraction device
Fig. 20. Radiographic presentation at the time of implant
placement.
Fig. 21. After integration, a provisional implant supported
restoration has been placed.
Fig. 22. Distraction in the posterior mandible with a KLS
Martin Track Plus.
Fig. 23. The SIS implant distractor in the start position
(left) and in full extension (right).
63
Distraction osteogenesis
(EverFab, East Aurora, NY) is also a combination oral
implant and distractor device (33).
Potential complications with
distraction osteogenesis
While the complication rate for distraction is fairly
low, a variety of complications such as infection,
extensive bleeding, nerve injury, adjacent tooth
damage, and ap dehiscence may occur. If the per-
iodontist is not prepared for the potential complica-
tions the treatment will more likely result in an
unfavorable outcome. With proper treatment plan-
ning and careful surgical manipulation, most of these
complications can be avoided. In addition to general
surgical complications, there are several potential
complications related to the alveolar distraction pro-
cedure itself.
Fracture of the host bone or transport segment
may occur during insertion of the distraction device,
or distraction xation screws. This is most often a
concern in narrow ridges of dense bone quality when
the transport segment dimensions are small. As a
result of fracture, the distractor, or distractor xation
screws, will lose stability and therefore should be
removed. In cases with insufcient distractor stabi-
lity it may be appropriate to remove the distractor,
place a bone graft and delay distraction surgery for 2
3 months. In order to prevent fracture of dense bone,
tapping is recommended during the ACE distractor
insertion. This avoids stress on the buccal plate of the
transport segment. For the distractors using a micro
screw xation system, a larger diameter drill before
placement may minimize damage to a transport seg-
ment with dense bone. Care should also be taken if
completion of the osteotomies is performed with an
osteotome, particularly near the maxillary sinus oor
and the piriform rim. It is recommended that only
the lateral walls be used for leverage of the transport
segment during mobilization.
Distractor instability can develop due to poor bone
quality, soft tissue dehiscence, transport or host seg-
ment fracture, or extensive site preparation for dis-
tractor placement. Placing the ACE distractor apical
enough to engage the wider implant shoulder will
increase distractor stability. Using longer or wider
diameter xation screws for situations of question-
able KLS or LEAD distractor stability can also
improve xation. If adequate distractor stability can-
not be obtained, the distractor must be moved to a
different location, or the site must be closed for later
distraction.
Either with a single distractor or multiple distrac-
tors, undesirable movement of the transport bone
segment may occur, often due to lingual ap or mus-
cle tension. A guidance axial distraction screw may
be utilized to maintain the desired direction of move-
ment or to correct malalignment with the ACE dis-
tractor. Temporary or orthodontic hardware may be
used with the KLS or LEAD distractors if segment
guidance is an issue. Making the lingual aspect of
the vertical cuts slightly convergent will also resist
undesirable segment movement, especially when lar-
ger transport segments are used that involve more
arch curvature.
When both vertical osteotomies are properly com-
pleted and the distraction rate is kept to 1 mm per day
or less, the transport segment should advance without
signicant resistance. If premature consolidation
occurs prior to completion of distraction, it is likely
due to incomplete osteotomy or mineralization at the
vertical osteotomy sites. In these cases, the transport
segment can be freed under local anesthesia by apply-
ing a nger pressure on the bone segment. Alterna-
tively, the transport segment premature consolidation
can be re-osteotomized using a small-size interdental
osteotome through a small incision. Keeping the ver-
tical osteotomies slightly divergent to the crestal
aspect will prevent segment binding and minimize
premature consolidation.
Typically, there is no detectable transport segment
mobility at the end of the consolidation period. In
some cases, however, delayed consolidation may
occur, potentially leading to the development of a
nonunion. If signicant transport segment mobility
exists at the proposed time of distractor removal, the
device may be left in place to allow further consoli-
dation. Sufcient stabilization of the transport seg-
ment is an important aspect in prevention of
nonunion during distraction. During active distrac-
tion and during the consolidation phase, segment
mobility must be controlled. In cases with an imma-
ture regeneration, nger pressure can be applied to
the transport segment at the time of distractor
removal to resist rotational forces, thereby stabilizing
the segment. In addition, immediate placement of
oral implants at this point will also support further
stabilization of the newly regenerated bone. Finally,
if a partial or complete nonunion exists at the nal
uncovering of the implants, debridement must be
performed followed by bone grafting and plate sta-
bilization.
While any of these complications are possible, the
publications to date indicate these complications
occur at a very low rate (4, 5, 12, 13, 20, 22). For
64
McAllister & Gaffaney
distraction cases involving sites that have had multi-
ple prior surgeries the incidence of complications is
higher (5), suggesting that distraction should be the
rst line of treatment rather than a last resort after
other techniques have failed. Considering there is no
established ideal bone augmentation approach for
the treatment of vertical defects, the minimal inci-
dence of complications gives further support to the
technique of distraction osteogenesis for treatment
of vertical defects.
Conclusions
Favorable clinical results have been observed for
alveolar ridge augmentation via distraction osteogen-
esis with the different distractor systems described.
These systems are relatively simple to apply and will
be a valuable adjunct to the contemporary implant
reconstruction armamentarium in periodontology.
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