J Oral Maxillofac Surg

63:1724-1730, 2005
Alveolar Width Distraction Osteogenesis
for Early Implant Placement
Zvi Laster, DDS,* Adi Rachmiel, DDS, and
Ole T. Jensen, DDS, MS
Distraction osteogenesis for correction of horizontal alveolar width deciency was performed for 9
patients by using an alveolar crest widening device. Four prototypes were used during the course of the
study until a nal protocol was achieved. Under local anesthesia, a blind crestal osteotomy was carried
out with minimal periosteal reection. The horizontal distraction device was placed percutaneously.
Distraction proceeded from the seventh postoperative day at a rate of 0.4 mm/day for 14 to 18 days.
Seven to 10 days later, dental implants were placed. Distraction osteogenesis occurred in all 9 patients
and increased alveolar width from 4 to 6 mm. Twenty implants successfully osteointegrated of 21 placed.
Marginal bone resorption was not observed after 12 months follow-up. The advantages of horizontal
distraction over block grafting include simultaneous expansion of soft tissue, high degree of dimensional
stability, abbreviated overall treatment time, and no graft requirement.
2005 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 63:1724-1730, 2005
The indications for alveolar ridge augmentation are
acquired or congenital alveolar defects. Acquired al-
veolar bone loss may be caused by post-extraction
defects, traumatic avulsion, periodontal disease, and/or
prolonged denture wear with subsequent disuse atro-
phy. In most of these cases the most signicant loss is
in the horizontal dimension. Traumatic tooth avulsion
with loss of the buccal bone plate is a typical example
of a situation leading to a horizontal defect.
1
Modalities to augment horizontal bone defects in-
clude autogenous onlay bone graft,
2,3
guided bone
regeneration,
4,5
alloplastic augmentation,
4,5
and alve-
olar split grafting.
1
Each of these modalities has its
advantages and disadvantages. Use of an autogenous
bone graft has donor site morbidity
6
and graft resorp-
tion is expected.
7
While guided bone regeneration
has been extensively documented,
4,5
it is often dif-
cult to provide optimal space for the regeneration of
the desired bone volume and is therefore better
suited for limited defects. Alloplastic materials
4,5
used
in quantity are not reliable for implant osseointegra-
tion.
Alveolar widening by distraction osteogenesis (DO)
is an alternative method for reconstructing alveolar
atrophy
8-11
that is similar to alveolar split grafting but
without the graft. The combination of vertical DO and
osseointegration has produced a stable esthetic recon-
struction of the alveolar bone and attached mucosa,
12
but the use of distraction to gain alveolar width, rst
reported by Aparicio and Jensen,
13
has not been fully
established clinically.
14
Block et al
15,16
conrmed isotropic augmentation
by DO for alveolar bone in animal studies. But, clinical
studies
17,18
have only established efcacy of alveolar
distraction in the vertical dimension because there are
few reports on the use of DO to gain width for dental
implants.
13,14,19-22
The purpose of this clinical study
was to establish, in a consecutive series of horizontal
alveolar distractions using the Laster Crest Widener
(Surgetek Inc, Brussels, Belgium), that dental implant
restoration could be consistently accomplished to an
optimized alveolar width morphology.
Materials and Methods
During the development of alveolar width distrac-
tion, 4 prototype devices were used on 9 patients
aged 18 to 52-years-old who presented with moder-
ately decient alveolar bone in the horizontal dimen-
sion.
The Laster Crest Widener consists of 4 sharp arms,
2 on each side connected with guide pins and an
activating distraction screw. By rotating the activating
*Professor and Director, Department of Oral and Maxillofacial
Surgery, Poriya Hospital, Poriya, Israel.
Professor and Director, Department of Oral and Maxillofacial
Surgery, Rambam Medical Center and the Bruce Rappaport Faculty
of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Private practice, Denver, CO.
Address correspondence and reprint requests to Dr Jensen: 303
Josephine St, Suite 303, Denver, CO 80206; e-mail: zvi@lasters.co.il
2005 American Association of Oral and Maxillofacial Surgeons
0278-2391/05/6312-0005$30.00/0
doi:10.1016/j.joms.2005.09.001
1724
screw, the pair of arms move apart, thus engaging
each side of the osteotomy site to spread it apart.
SURGICAL TECHNIQUE
Under local anesthesia, a crestal mucoperiosteal
incision is made followed by buccal vertical muco-
periosteal incisions placed anterior and posterior to
the distraction zone (Fig 1). The crest itself is mini-
mally exposed, otherwise there is no ap reection. A
round burr is used to make a small trough along the
crest. Bone cuts are made through the trough, and
through the anterior and posterior vertical incisions
without stripping mucoperiostium using a sagittal
micro saw, reciprocating scalpel saw, or piezoelectric
ultrasonic bone cutter (Fig 2). An osteotome is intro-
duced crestally and the buccal plate is green-stick
fractured bucally (Fig 3). The distractor is tapped into
place and the wound is approximated with sutures. A
provisional prosthesis is then placed (Figs 4, 5). Dis-
traction begins 1 week later by turning the activating
screw 2 and 1/2 turns per day (0.4 mm). This is done
by the patient at home (Fig 6). After a 7- to 10-day
retention period for early bone consolidation, the
distraction device is removed and 1 week later im-
plants are inserted percutaneously. In 1 case (no. 3)
the periostium was stripped buccally to make a stop
cut in the vestibule before out-fracturing the segment
(Fig 7). Pressure or mastication on the distraction site
by a temporary denture is avoided during distraction,
consolidation, and osseointegration. The exposure of
dental implants is performed 3 to 4 months after
insertion, and prosthetic rehabilitation completed
thereafter (Fig 8). Panoramic and periapical x-rays are
taken following distraction, after implant placement,
and at 1-year intervals.
Results
Nine patients underwent horizontal expansion of
the alveolar process by DO followed by dental im-
plant placement. The distraction was evident clini-
cally and radiographically. Alveolae increased in
width between 4 and 6 mm (Table 1). The attached
mucosa at the top of the alveolar crest increased
simultaneous to increased bone mass.
No infections resulted from treatment. Of 23
threaded implants placed, 22 implants osseointe-
grated. The post-distraction follow-up period was
from 6 to 24 months. No signicant marginal bone
resorption was observed after implant placement, ex-
cept in case no. 3, where reection of a mucoperios-
FIGURE 1. A crestal mucoperiosteal incision is made along the
desired area for widening, followed by vertical mucoperiosteal inci-
sions anteriorly and posteriorly.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 2. Bone cuts are made through the trough, and the anterior
and posterior vertical incisions without stripping the mucoperiostium
using a sagittal micro saw, a reciprocating scalpel saw, or piezoelec-
tric bone cutter.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 3. An osteotome is introduced and the buccal plate is
green-stick fractured bucally.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
LASTER, RACHMIEL, AND JENSEN 1725
teal ap was performed. This resulted in loss of bone
and exposed screw threads in 2 implants that were
prosthetically rehabilitated.
One implant failed to integrate because of inade-
quate primary stability but was successfully replaced
8 weeks later. All implants were loaded with dental
prostheses.
Discussion
Reconstruction of the decient alveolar process
should address deciency of both bone and attached
mucosa. Experimental distraction studies
23
have re-
ported lamellar bone formation as well as histogenesis
of soft tissue. This process has also been veried
clinically.
24,25
Because DO provides a simultaneous and general-
ized histogenesis it eliminates the need for both bone
and soft tissue grafting in implant cases.
17,26,27
Hori-
zontal distraction is especially useful in moderately
narrow alveolar ridges which still have sufcient ver-
tical height.
Nosaka et al
20
performed an experimental study on
narrowed alveolar ridges in 6 beagle dogs, widening
the alveolus by distraction. Twelve days after comple-
tion of distraction, during consolidation, screw-type
endosseous implants were placed into the distracted
area. After 24 weeks the implants were found to be
embedded in mature bone. Direct bone contact with
the implant surface was observed without scar forma-
FIGURE 4. The device is tapped into place and the wound is closed
primarily.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 5. A provisional prosthesis is then placed.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 6. The distraction begins 1 week later by turning the distrac-
tion rod 2 turns per day (0.4 mm.) This is done by the patient at
home.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 7. In 1 case (no. 3) the periostium was stripped buccally to
make a stop cut in the vestibule before out-fracturing the segment.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
1726 ALVEOLAR WIDTH DO FOR EARLY IMPLANT PLACEMENT
tion, admixture of dead bone, or evidence of vascular
embarrassment as found in bone graft settings.
This study shows that horizontal alveolar ridge dis-
traction is a reasonable adjunct for placement of im-
plants in the moderately atrophic alveolus. Osseointe-
gration is achieved despite implants being placed into
regenerate during the early stage of consolidation.
Providing there is primary implant stability, osseointe-
gration occurs without signicant disruption of the
regenerative process. And, resorption of the superior
aspect of the alveolar ridge was not observed when
the ap procedure was minimal.
HORIZONTAL DISTRACTION
OSTEOGENESIS PROTOCOL
Despite alteration of the distraction protocol during
this clinical study, there was no signicant difference
in nal outcome, with the exception of case no. 3.
The following summarizes a proposed best technique
for horizontal distraction:
STEP-BY-STEP PROCEDURE
1) Under local anesthesia, a crestal incision is
made, followed by vertical incisions anteriorly
and posteriorly. Flaps are not reected, instead
the crest is minimally exposed and by using a
small round burr a trough is made mid-crestally.
2) A bone cut follows the trough to a depth of at
least 10 mm using a reciprocating saw or piezo-
electric knife. Bone cuts are made through the
anterior and posterior vertical incisions using a
sagittal micro saw (Figs 9, 10).
3) A thin osteotome is used to out-fracture the buccal
plate and then the wound is closed (Fig 11).
4) One week later the Laster Crest Widener is
tapped into place percutaneously (Fig 12).
5) A titanium safety wire is threaded through the
hole in the arm (this is best performed before
the insertion of the device) (Fig 13).
6) Two counter-clockwise rotations are made with
the activation screw to engage the device in
bone and conrm mobilization of the transport.
FIGURE 8. The exposure of dental implants was performed 3 to 4
months after their insertion, and the prosthetic rehabilitation completed
thereafter.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
Table 1. DEFICIENT ALVEOLAR BONE, PRIMARY DATA OF PATIENTS
Patient Age Area of Widening Length of Expansion (mm) No. of Implants
Z.I. (M) 45 34, 35, 36, 37 (Lt mandibular body) 5 4
G.Y. (M) 40 13, 14, 15, 16 (Rt maxilla) 6 4
M.O. (F) 33 46, 47 (Rt mandibular body) 4 2
G.S. (M) 50 46, 47 (Rt mandibular body) 5 2
P.D. (F) 52 32, 42 (Anterior mandible) 4 2
Z.Y. (F) 48 46, 47 (Rt mandibular body) 4 2
D.L. (M) 18 11, 12 (Anterior maxilla) 5 2
E.E. (M) 38 11, 12, 21 (Anterior maxilla) 4 3
T.Y. (F) 25 46, 47 (Rt mandibular body) 4 2
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Implant Placement. J Oral Maxillofac Surg 2005.
FIGURE 9. Anterior and posterior vertical incisions are made through
the mucoperiostium.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
LASTER, RACHMIEL, AND JENSEN 1727
7) Activation begins immediately at a recom-
mended rate of 0.4 mm per day ( a turn twice
a day.) The patient should be examined by the
surgeon every 4 days.
8) Once sufcient width is achieved (10 to 14
days), activation is stopped. (Overdistraction of
1 to 2 mm is recommended.) The Laster Crest
Widener is left in for a brief 7- to 10-day consol-
idation. The device is then removed under local
anesthesia without soft tissue closure (Fig 14).
9) Dental implantation is performed immediately
or 7 to 10 days after removal of the crest wid-
ener despite incomplete mineralization (Fig 15).
Implant placement is performed transgingivally
(Fig 16).
Advantages of Distraction
Osteogenesis Over Bone Grafting
The advantage of DO is that there is little or no
bone resorption as typically occurs in bone graft re-
construction. Although relapse of the distraction may
occur, it is likely within the regenerate (away from
the buccal bone plate that establishes alveolar form
and provides osseous coverage of the implant).
Another advantage of distraction is the concomi-
tant proliferation of attached gingiva, obviating the
need for soft tissue augmentation. Therefore, DO
avoids donor site morbidity associated with both hard
and soft tissue harvest.
There may also be less relapse with alveolar distrac-
tion over other approaches. Rachmiel et al, in a 1-year
FIGURE 10. Bone cuts are made through the facial plate using a
sagittal saw.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 11. A thin osteotome is used to out-fracture the buccal
plate.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 12. One week later the Laster Crest Widener is tapped into
place percutaneously.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 13. A titanium safety wire is threaded through the hole in the
arm.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
1728 ALVEOLAR WIDTH DO FOR EARLY IMPLANT PLACEMENT
follow-up experimental study, found a 7% relapse
after a 40-mm total maxillary advancement.
25,26,28
The
relapse for small dimension horizontal distraction is
negligible because the regenerate is quick to mature
into lamellar bone.
19,26
The process of bone graft
incorporation and creeping substitution is completely
avoided.
Another advantage to distraction is timing for im-
plant placement. Early regenerate mineralization pro-
ceeds by thickening of bony trabeculae. Implants
placed during this relatively short time frame (4 to 8
weeks postoperative) heal in about half the time re-
quired for a staged block graft.
Therefore, DO for width enhancement is relatively
simple to perform, quicker to heal than bone grafts,
minimally traumatic, and dimensionally stable.
One disadvantage, however, is the second proce-
dure required for device removal, although it is easily
performed without the need for an incision.
In general, the result of the distraction process for
width enhancement resulted in an esthetic and func-
tional prosthetic reconstruction, with a more favor-
able axial implant placement and improved orthoal-
veolar inter-arch relation.
Summary
A pilot study was performed using horizontal alve-
olar distraction to treat edentulous sites with moder-
ate horizontal atrophy. Sufcient generation of new
bone allowed stable dental implant restorations. Soft
tissue proliferation added to the hard tissue augmen-
tation.
Alveolar distraction may be useful for augmenting
the atrophic alveolus in select cases providing the
advantage of less overall treatment time than standard
staged bone grafting techniques as well as avoiding
second site surgery.
Further study of the technique with long-term fol-
low-up to conrm bone and implant stability as it
relates to alveolar width is needed.
References
1. Oikarinen KS, Sandor GK, Kainulainen VT, et al: Augmentation
of the narrow traumatized anterior alveolar ridge to facilitate
dental implant placement. Dent Traumatol 19:19, 2003
2. Nystrm E, Kahnberg K-E, Gunne J: Bone grafts and Branemark
implants in the treatment of severely resorbed maxilla: A two-
year longitudinal study. Int J Oral Maxillofac Implant 8:45, 1993
3. Triplett RG, Schow SR: Autologous bone grafts and endosseous
implants: Complementary techniques. J Oral Maxillofac Surg
54:489, 1996
4. Caplanis N, Sigurdsson TJ, Rohrer MD, et al: Effect of alloge-
neic, freeze-dried, demineralized bone matrix on guided bone
FIGURE 14. The Laster Crest Widener is left for a brief 7- to 10-day
consolidation period, then the device is removed under local anesthe-
sia without soft tissue closure.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 15. Dental implant placement is performed 7 to 10 days
after device removal despite incomplete mineralization.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
FIGURE 16. Implant placement is performed percutaneously.
Laster, Rachmiel, and Jensen. Alveolar Width DO for Early Im-
plant Placement. J Oral Maxillofac Surg 2005.
LASTER, RACHMIEL, AND JENSEN 1729
regeneration in supra-alveolar peri-implant defects in dogs. Int
J Oral Maxillofac Implant 12:634, 1997
5. Jensen OT, Greer RO Jr, Johnson L, et al: Vertical guided
bone-graft augmentation in a new canine mandibular model.
Int J Oral Maxillofac Implant 10:355, 1995
6. Laurie SW, Kaban LB, Mulliken JB: Donor site morbidity after
harvesting rib and iliac bone. Plast Reconstr Surg 73:933, 1984
7. von Arx T, Hardt N, Wallkamm B: The TIME technique: A new
technique for localized alveolar ridge augmentation prior to
placement of dental implants. Int J Oral Maxillofac Implant
1:387, 1996
8. Karp NS, McCarthy JG, Schreiber JS, et al: Membranous bone
lengthening: A serial histological study. Ann Plast Surg 29:2,
1992
9. Rachmiel A, Laufer D, Jackson IT, et al: Midface membranous
bone lengthening: A one-year histological and morphological
follow-up of distraction osteogenesis. Calcif Tissue Int 62:370,
1998
10. McCarthy JG, Schreiber J, Karp N, et al: Lengthening the
human mandible by gradual distraction. Plast Reconstr Surg
89:1, 1992
11. Rachmiel A, Levy M, Laufer D: Lengthening of the mandible by
distraction osteogenesis. J Oral Maxillofac Surg 53:838, 1995
12. Jensen OT, Cockrell R, Kuhlke L, et al: Anterior maxillary
alveolar distraction osteogenesis: A 5 year study. Int J Oral
Maxillofac Surg 17:52, 2002
13. Aparicio C, Jensen OT: Alveolar distraction to gain width, in
Jensen OT (ed): Alveolar Distraction Osteogenesis. Chicago, IL,
Quintessence, 2002, pp 133-148
14. Aparicio C, Jensen OT: Alveolar ridge widening by distraction
osteogenesis: A case report. Pract Proc Aesthetic Dent 13:663,
2001
15. Block MS, Almerico B, Crawford C, et al: Bone response to
functioning implants in dog mandibular alveolar ridges aug-
mented with distraction osteogenesis. Int J Oral Maxillofac
Implant 13:342, 1998
16. Block MS, Chang A, Crawford C: Mandibular alveolar ridge
augmentation in the dog using distraction osteogenesis. J Oral
Maxillofac Surg 54:309, 1996
17. Rachmiel A, Srouji S, Peled M: Alveolar ridge augmentation by
distraction osteogenesis. Int J Oral Maxillofac Surg 30:510,
2001
18. Gaggl A, Shultes G, Krcher H: Distraction implants A new
possibility for augmentative treatment of the edentulous atro-
phic mandible: Case report. Br J Oral Maxillofac Surg 37:481,
1999
19. Hidding J, Lazar F, Zoller JE: Initial outcome of vertical distrac-
tion osteogenesis of the atrophic alveolar ridge. Mund Kiefer
Gesichtschir 3:S79, 1999
20. Nosaka Y, Kitano S, Wada K, et al: Endosseous implants in
horizontal alveolar ridge distraction osteogenesis. Int J Oral
Maxillofac Implant 17:846, 2002
21. Takahashi T, Funaki K, Shintani H, et al: Use of horizontal
alveolar distraction osteogenesis for implant placement in a
narrow alveolar ridge: A case report. Int J Oral Maxillofac
Implant 19:291, 2004
22. Oda T, Suzuki H, Yokota M, et al: Horizontal alveolar distrac-
tion of the narrow maxillary ridge for implant placement. J Oral
Maxillofac Surg 62:1530, 2004
23. Niederhagen B, Braumann B, Schmolke C, et al: Tooth-borne
distraction of the mandible. An experimental study. Int J Oral
Maxillofac Surg 28:475, 1999
24. Oda T, Sawaki Y, Ueda M: Alveolar ridge augmentation by
distraction osteogenesis using titanium implants: An experi-
mental study. Int J Oral Maxillofac Surg 28:151, 1999
25. Rachmiel A, Jackson IT, Potparic Z, et al: Midface advancement
in sheep by gradual distraction: A one year follow-up study.
J Oral Maxillofac Surg 53:525, 1995
26. Garcia-Garcia A, Somoza-Martin M, Gandara-Vila P, et al: Hori-
zontal alveolar distraction: A surgical technique with the trans-
port segment pedicled to the mucoperiosteum. J Oral Maxillo-
fac Surg 62:1408, 2004
27. Niederhagen B, Braumann B, Berge S, et al: Tooth-borne dis-
traction to widen the mandible. Int J Oral Maxillofac Surg
29:27, 2000
28. Rachmiel A, Rozen N, Peled M, et al: Characterization of mid-
face maxillary membranous bone formation during distraction
osteogenesis. Plast Reconstr Surg 109:1611, 2002
1730 ALVEOLAR WIDTH DO FOR EARLY IMPLANT PLACEMENT