Periodontology 2000, Vol.

33, 2003, 5466

Printed in Denmark. All rights reserved

Copyright # Blackwell Munksgaard 2003

PERIODONTOLOGY 2000
ISSN 0906-6713

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 vertical augmentation of the mandible and maxilla prior
to implant reconstruction (6). With such a short history 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 distraction osteogenesis has been extensively investigated
and successfully applied to a variety of bone problems over the last century.
While no controlled long-term studies exist with any
of the commercially available alveolar bone devices
available today, excellent case reports and animal studies exist for the distraction devices currently available. 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-

54

bilizing unthreaded base plate (6). Additional case

reports have been published over the past few years
with intraosseous, extraosseous and implant distractors (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 available (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 demonstrating successful vertical augmentation. Customized
ossseointegrated implant supported distraction devices were utilized in dog mandibles to gain 9 mm of
vertical augmentation. The regenerated bone was evaluated 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 colleagues have evaluated both a two-stage and single-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.

Distraction osteogenesis

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 in growth factor
and cytokine gene expression have been demonstrated 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 distraction 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 osseous defect. In the event teeth adjacent to the edentulous 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 improvement. 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 complication when distracted and should usually be treated with conventional bone grafting techniques (20).
While it is desirable to perform distraction under
conscious sedation or general anesthesia, it is possible to perform the surgical procedure using only
regional anesthesia. Either a vestibular mucosal incision 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 distractor placement, distractor xation and nal osteot-

omy preparation is specic to the system being

used. Once the distractor is placed and the osteotomies are complete, device function is tested to
make sure that there are no interferences. If the vertical osteotomies slightly converge to the coronal,
and to the lingual aspect, there will be little risk for
interference problems. Suturing can be easily accomplished 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, distraction 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 distraction, 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, indicating 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 osteotomies and the transport segment resulting in a
higher incidence of non-union or incomplete distraction gap ossication.
Distractor removal and implant placement will be
performed during the consolidation phase. It is possible to place implants at the time of distractor

55

McAllister & Gaffaney

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 proposed 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 supplemental 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 prosthetic loading of the dental implants placed in distracted bone.

The intraosseous ACE distractor (ACE Surgical Supply, Brockton, MA) is made of titanium alloy and has
three main components during active distraction
(Fig. 1). The distractor body engages the bony transport 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 maximal xation. The axial distraction screw is threaded
through the distractor body and used for active distraction. The base plug has an internally threaded
hole in which the axial distraction screw sits and
engages for the distraction process. As the axial distractor 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.

ACE surgical distractor

56

Distraction osteogenesis

Fig. 2. Radiographic view of the vertical bone loss.

Fig. 4. Radiographic view at the completion of approximately 8 mm of distraction.

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 regeneration zone (Figs 5 and 6). After a standard integration period the implants were restored and loaded.

Fig. 3. The segment after placement of the distractor and

completion of both the horizontal and vertical osteotomies
to mobilize the segment.

Fig. 5. Two 18-mm implants have been placed and a

biopsy was taken from the regeneration zone.

57

McAllister & Gaffaney

Fig. 7. The radiographic view of the distraction case after

3 years.

three missing teeth up to a maximum of three distractors. Following 2 months of consolidation, implants 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 containing more mature lamellar bone (original magnication
40) (Stevenel's blue Van Gieson's picric fuchsin stain).

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 periodontitis. 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

58

Fig. 8. Surgical view after the reection of only the buccal

mucoperiosteal ap prior to the placement of two ACE
distractors.

Distraction osteogenesis

Fig. 9. Radiographic view at the completion of approximately 8 mm of distraction with 2 mm of overcorrection.

The guidance axial distraction screw is engaging the orthodontic band retained lingual arch wire xed/removable
temporary.

temporary be utilized to insure proper transport segment 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 contains both the base plug and the distractor body, so
instability is not likely to occur. Radiographic conrmation 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 mm diameter threaded
rod, a threaded transport plate, and a stabilizing
unthreaded base plate (Fig. 11). The threaded distraction rod comes in 17, 22 and 32 mm lengths and can be
advanced 0.4 mm per turn. The angle of the osteotomy

Fig. 10. The nal restoration after consolidation (a, b).

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 to ensure the transport segment is

59

McAllister & Gaffaney

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.

Fig. 11. The LEAD system showing the threaded rod, stabilizing base plate and threaded transport plate.

orientated correctly with this system (Figs 13 and 14).

With the narrow nature of the threaded rod it is important not to apply too much horizontal force as bone
resorption can occur and the rod may become displaced from the transport segment. With the narrow
threaded rod a vestibular incision can be made and
drilling the threaded rod osteotomy can be made without 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 system have shown favorable
results (6, 12, 13).

KLS Martin distractor

Fig. 12. The LEAD system xated in place after the completion of the horizontal and vertical osteotomies.

60

The extraosseous Track distractors (KLS Martin, Jacksonville, 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.

Distraction osteogenesis

Fig. 15. continued

Fig. 15. The KLS distractors: (a) Track 1.5, (b) Track Plus
and (c) Track 1.0.

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, Osteohealth, 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 osteotomies were marked, the device removed, the osteotomies 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).

61

McAllister & Gaffaney

Fig. 16. Initial radiographic appearance showing extensive evidence of bone loss on teeth 12, 11 and 21.

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 necessary 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

Fig. 17. The KLS Martin Track Plus fully xated with
completed vertical and horizontal osteotomies prior to
suturing.

62

Fig. 18. Radiographic appearance at the completion of

6 mm of distraction.

insufcient number of patients have been treated for

a predictive incidence of nerve damage from the
distraction osteotomies in this area to be determined. 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. 19. At the end of the consolidation phase, excellent

vertical height can be appreciated.

Distraction osteogenesis

Fig. 23. The SIS implant distractor in the start position

(left) and in full extension (right).

Fig. 20. Radiographic presentation at the time of implant

placement.

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 regeneration. 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
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.

The concept of a prosthetically restorable distractor

(Fig. 23) was introduced by SIS Trade Systems (Klagenfurt, Austria). A histologic study in sheep has
demonstrated that this distractor becomes osseointegrated 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 placement are eliminated. There are, however, several
major complications of concern that could arise specic 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 prosthetic position due to the interference of the
vertical osteotomies. The Veriplant distraction device

63

McAllister & Gaffaney

(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 periodontist is not prepared for the potential complications the treatment will more likely result in an
unfavorable outcome. With proper treatment planning 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 procedure 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 stability 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 segment 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 segment fracture, or extensive site preparation for distractor 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 questionable KLS or LEAD distractor stability can also
improve xation. If adequate distractor stability cannot be obtained, the distractor must be moved to a
different location, or the site must be closed for later
distraction.

64

Either with a single distractor or multiple distractors, undesirable movement of the transport bone
segment may occur, often due to lingual ap or muscle tension. A guidance axial distraction screw may
be utilized to maintain the desired direction of movement or to correct malalignment with the ACE distractor. 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 larger transport segments are used that involve more
arch curvature.
When both vertical osteotomies are properly completed 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 applying a nger pressure on the bone segment. Alternatively, the transport segment premature consolidation
can be re-osteotomized using a small-size interdental
osteotome through a small incision. Keeping the vertical 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 consolidation. Sufcient stabilization of the transport segment is an important aspect in prevention of
nonunion during distraction. During active distraction and during the consolidation phase, segment
mobility must be controlled. In cases with an immature 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 stabilization.
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

Distraction osteogenesis

distraction cases involving sites that have had multiple 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 incidence of complications gives further support to the
technique of distraction osteogenesis for treatment
of vertical defects.

11.

12.

13.

14.

Conclusions

15.

Favorable clinical results have been observed for

alveolar ridge augmentation via distraction osteogenesis 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.

16.

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19.

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