YIJOM-3752; No of Pages 8

Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2017.07.007, available online at http://www.sciencedirect.com

Clinical Paper
Pre-Implant Surgery

Two-stage reconstruction of the A. Rachmiel1,2, O. Emodi1,2,

D. Aizenbud2,3, D. Rachmiel4,
D. Shilo1

severely deficient alveolar ridge:

1
Department of Oral and Maxillofacial
Surgery, Rambam Medical Care Center,
Haifa, Israel; 2Ruth and Bruce Rappaport
Faculty of Medicine at the Technion-Israel

bone graft followed by alveolar Institute of Technology, Haifa, Israel;

3
Department of Orthodontics and Cleft
Palate, School of Dental Surgery, Rambam
Medical Care Center, Haifa, Israel; 4School of
distraction osteogenesis Dental Medicine, Tel Aviv University, Tel Aviv,
Israel

A. Rachmiel, O. Emodi, D. Aizenbud, D. Rachmiel, D. Shilo: Two-stage reconstruction

of the severely deficient alveolar ridge: bone graft followed by alveolar distraction
osteogenesis. Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx. ã 2017 International
Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.

Abstract. Distraction osteogenesis for the augmentation of severe alveolar bone

deficiency has gained popularity during the past two decades. In cases where the
vertical bone height is not sufficient to create a stable transport segment, performing
alveolar distraction osteogenesis (ADO) is not possible. In these severe cases, a two-
stage treatment protocol is suggested: onlay bone grafting followed by ADO. An
iliac crest onlay bone graft followed by ADO was performed in 13 patients: seven in
the mandible and six in the maxilla. Following ADO, endosseous implants and
prosthetic restorations were placed. In all cases, the onlay bone graft resulted in
inadequate height for implant placement, but allowed ADO to be performed. ADO
was performed to a mean total vertical augmentation of 13.7 mm. Fifty-two
endosseous implants were placed. During a mean follow-up of 4.85 years, two
implants failed, both during the first 6 months; the survival rate was 96.15%. In
severe cases lacking the required bone for ADO, using an onlay bone graft as a first
Key words: alveolar distraction osteogenesis;
stage treatment increases the bone height thus allowing ADO to be performed. This bone graft; augmentation; pre-prosthetic sur-
article describes a safe and stable two-stage treatment modality for severely gery.
atrophic cases, resulting in sufficient bone for implant placement and correction of
the inter-maxillary vertical relationship. Accepted for publication

Bone regeneration is one of the main re-
search fields for craniofacial surgeons, as
well as orthopedic surgeons. Current re-
search is aimed at identifying the ideal oste-
ogenic molecule or scaffold and improving
tissue engineering techniques for bone re-
generation. In the meantime, surgeons have
to use the resources that are available.
Since the beginning of the dental im-
plant era, the demand for stable and prop-
erly aligned facial and dental prosthetic
rehabilitation has increased continuously.
Patients with severely deficient alveolar
bone are no longer satisfied with tissue-
borne dental prostheses and are requesting
better solutions.
A few methods for augmentation are
available to the surgeon facing mild to
moderate deficiencies: autogenous onlay
bone grafting1,2, the interpositional bone
graft3, guided bone regeneration (GBR)4,5,
alloplastic materials4,5, and inferior alve-
olar nerve lateralization6. However, sig-
nificant resorption occurs in autogenous

0901-5027/000001+08 ã 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Rachmiel A, et al. Two-stage reconstruction of the severely deficient alveolar ridge: bone graft
followed by alveolar distraction osteogenesis, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.07.007
YIJOM-3752; No of Pages 8

2 Rachmiel et al.

onlay bone grafts, mostly due to inade- lower plate of the distractor is fixed. In In severely deficient alveolar ridges,
quate soft tissue coverage7. GBR is used the maxilla, disruption of the nasal floor/ where the vertical bone height is insuffi-
widely for minor deficiencies and is limit- maxillary sinus should always be avoided. cient to create a stable transport segment,
ed in gaining significant bone height and In the authors’ practice, it is aimed to it is not possible to perform ADO. In these
volume4,5. Alloplastic materials should be maintain a minimum distance of 3 mm severe cases, a two-stage treatment mo-
avoided in large vertical defects4,5. of bone below the nasal floor in the ante- dality is suggested: onlay bone grafting
None of the methods mentioned above is rior maxilla (Fig. 1). In the anterior man- followed by ADO.
adequate in cases of severe bone deficiency. dible, sufficient basal bone should be
When used for large vertical defects, the maintained to avoid fractures and to per-
results are inconsistent, not completely pre- mit fixation of the basal plate; it is aimed Materials and methods
dictable, and lack stability. In addition, to maintain at least 6 mm of basal bone A retrospective study was performed of
these methods do not approach the soft (Fig. 2). In severely deficient mandible patients suffering from severe alveolar
tissue deficiency accompanying the bony cases, another anatomical consideration bone loss and treated with a two-stage
deficiency. For this reason, distraction os- is the inferior alveolar nerve; it is aimed procedure: onlay bone grafting followed
teogenesis (DO) for alveolar bone augmen- to maintain a safe distance of 2 mm from by ADO. The cases of all patients treated
tation has been used in severe cases during the nerve (Fig. 3). with the two-stage modality between the
the past two decades8–10.
DO is a method of generating new bone
involving a corticotomy or an osteotomy
and gradual elongation. The method is
based on the tension–stress principle de-
scribed by Ilizarov11,12. Gradual bone
elongation stimulates molecular
responses, promoting the differentiation
of stem cells, angiogenesis, osteogenesis,
bone mineralization, and thus bone
formation13–16. There are four stages to
DO: (1) osteotomy and fixation of the
distraction device; (2) a latency period
of several days for primary callous orga-
nization; (3) gradual elongation at a rate of Fig. 1. Alveolar distraction osteogenesis in the maxilla: (A) enough bone to create a transport
0.5–1 mm/day; (4) a consolidation period segment for ADO; (B) the remnant basal bone (arrow) is not adequate for the creation of a
of 4 months for callous maturation and transport segment without increasing the risk of fracture of the basal bone.
mineralization.
DO has been shown to be predictable in
the facial bones in animal studies13,14. This
method was used clinically for the first time
in the maxillofacial region by McCarthy
et al. for mandibular elongation in syndro-
mic children17. Since then, it has been used
in clinical practice for elongation of the
mandible, maxilla, and midface17–22.
Alveolar distraction osteogenesis (ADO)
has been applied for bone augmentation of
the severely deficient alveolar ridge prior to Fig. 2. Alveolar distraction osteogenesis in the anterior mandible: (A) enough bone to create a
dental implant placement8,10,23,24. ADO in transport segment for ADO; (B) the remnant basal bone (arrow) is not adequate for the creation
the anterior region has most often been of a transport segment without increasing the risk of fracture of the basal bone.
performed in the maxilla25, but it can also
be performed in the anterior mandible to
allow inter-foraminal implant placement
for an overdenture26,27. ADO in the poste-
rior region has most often been performed
in the mandible, to improve the crown to
implant ratio28,29.
The generation of new bone during
distraction depends on the traction of
two bony segments: the transport segment
and the basal segment. In order to perform
ADO, the crestal transported segment has
to have a minimum height of 6 mm. This
height is essential for fixation of the device
and to avoid fracture of the segment8,29. A Fig. 3. Alveolar distraction osteogenesis in the posterior mandible: (A) enough bone to create a
second important consideration is the in- transport segment for ADO; (B) the bone over the inferior alveolar nerve (arrow) is not adequate
tegrity of the basal bone on which the for the creation of a transport segment without damaging the nerve.

Please cite this article in press as: Rachmiel A, et al. Two-stage reconstruction of the severely deficient alveolar ridge: bone graft
followed by alveolar distraction osteogenesis, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.07.007
YIJOM-3752; No of Pages 8
years 2004 and 2015 were retrieved. No
cases were excluded. Data retrieved in-
cluded the etiology of the bone deficiency,
location of the deficiency, bone height
achieved following onlay bone grafting,
bone height achieved following ADO,
number of implants inserted, survival of
implants, and duration of follow-up.
Onlay bone grafting followed by ADO
was performed in 13 patients. Seven of
these patients were treated for a deficiency
in the mandible and six were treated for a
deficiency in the maxilla. Preoperative
clinical examinations and radiographs, in-
cluding a panoramic radiograph and a
lateral cephalometric X-ray, revealed se-
vere alveolar atrophy of class V–VI
according to the classification of Cawood
and Howell30.
With regard to the etiology, four
patients suffered an alveolar deficiency
following tumor resection, four following
trauma, three following gunshot wounds,
and two following bone atrophy.
All bone grafts were collected from the
anterior iliac crest. The size of the bone
graft varied depending on the defect in the
alveolar bone. Onlay bone grafting was
performed as follows: a paracrestal muco-
periosteal incision was made and the alve-
olar crest was exposed. Preparation of the
recipient site was performed by decortica-
tion of the alveolar crest. The harvested
Fig. 4. Severe alveolar bone deficiency: (A) clinical photograph showing collapse of the lower lip due to a lack of bony and dental support; (B)
intraoral clinical photograph showing the severe alveolar bone deficiency; (C) panoramic X-ray and (D) computed tomography showing the severe
alveolar bone defect.
Please cite this article in press as: Rachmiel A, et al. Two-stage reconstruction of the severely deficient alveolar ridge: bone graft
followed by alveolar distraction osteogenesis, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.07.007
Two-stage reconstruction of the alveolar ridge
iliac crest bone graft was placed and fix-
ated using positional screws or miniplates.
Release of the flap is mandatory; both
lateral mucoperiosteal release incisions
and incisions in the periosteum of the
raised flap were included. The flap was
advanced and watertight sutures were
placed using nylon suture material.
The ADO procedure was performed as
follows: a paracrestal mucoperiosteal in-
cision was performed on the buccal side,
leaving the crestal attached mucosa intact.
Previous bone graft fixation screws or
miniplates were removed. Two vertical
osteotomies and one horizontal osteotomy
were performed to create a trapezoidal
osteotomy that formed the transport seg-
ment. Fixation of the distractors was done
using miniscrews (KLS Martin, Tuttlin-
gen, Germany). Bone elongation was ini-
tiated after a latency period of several days
at a rate of 0.5 mm/day and continued as
necessary and according to the length of
the distraction device. An overcorrection
of 1–2 mm of alveolar bone elongation
was performed. In cases of deviation from
the planned vector of elongation, a palatal
or lingual arch and elastics were used.
Following bone elongation, a consolida-
tion period of 4 months was required.
Subsequently, the devices were removed
and endosseous implants placed, followed
by delivery of the prosthetic restoration.
3
Table 1. Protocol for the two-stage recon-
struction of a severe alveolar ridge deficiency.
1 First surgery: onlay bone graft
2 Second surgery: osteotomy and distractor
placement
At least 6 months following first surgery
3 Latency period
4 days
4 Rate of bone elongation
0.5 mm/day as necessary
5 Consolidation period
4 months
6 Device removal
7 Implant placement
Minor bone reduction of 1–2 mm was
performed at the time of implant place-
ment in six of the patients, due to over-
correction.
The timing of the procedures is detailed
in Table 1.
Results
All cases showed severe alveolar bone
deficiency that did not allow ADO to be
performed (Fig. 4). An onlay bone graft
was performed in all cases (Fig. 5). Due to
severe deficiency, the defect could not be
reconstructed solely with the free bone
graft.
Partial exposure of the onlay bone graft
was observed in five of the 13 patients, all
YIJOM-3752; No of Pages 8

4 Rachmiel et al.

Fig. 5. First stage of augmentation using an
onlay bone graft: (A) panoramic X-ray follow-
ing iliac crest onlay bone grafting to the alveolar
mandibular defect; (B) intraoral clinical photo-
graph following the onlay bone graft.
of them during the first week. All cases were
resolved by soft tissue debridement, re-su-
turing, antimicrobial rinses, meticulous oral
hygiene, and systemic antibiotics.
The onlay bone graft resulted in an
inadequate height for implant placement
in the correct implant to crown ratio in all
cases, but allowed for ADO to be carried
out.
An osteotomy was performed and alve-
olar distractors were fixated (Fig. 6).
Vertical alveolar distraction was per-
formed and the transported segment was
elongated at a rate of 0.5 mm/day to a
Fig. 6. Alveolar distraction osteogenesis at least 6 months following bone graft placement: (A)
clinical photograph showing the osteotomy and fixation of two distractor devices; (B) panoramic
X-ray following alveolar distractor placement before the commencement of elongation.
mean total of 13.7 mm (range 13– Discussion
14 mm) (Table 2, Fig. 7).
Large alveolar bony defects cannot be
Fifty-two endosseous implants (Zim-
reconstructed solely using an onlay bone
mer Dental, Carlsbad, CA, USA) were
graft due to the high rates of resorption7.
placed in the newly created alveolar bone
ADO is a procedure in which a segment of
(Fig. 8A). Over a mean follow-up of 4.85
mature bone is transported in order to
years, 50 implants were osseointegrated;
lengthen the alveolar crest for better im-
two implants failed to osseointegrate dur-
plant anchorage, either for aesthetic pur-
ing the first 6 months. Thus the survival
poses or for functional prosthetic or
rate was 96.15% (Table 2). A life-table
occlusal requirements.
analysis was conducted (Table 3). Im-
ADO is an appropriate solution as long
plant-based rehabilitation was performed
as there is enough existing bone to create
in all cases (Figs 8 B and 9 ).
both a stable transport segment and a basal
Figures 4–9 show the treatment of a
segment, without the risk of bone fracture
patient with a severe alveolar bone defi-
or nerve damage. However, in severe
ciency in the mandible. Figs 10–14 present
cases in which there is insufficient bone
a case of two-stage maxillary vertical
for ADO, the use of an onlay bone graft as
elongation.
a first stage, thereby increasing the bone

Table 2. Details of the 13 patients subjected to two-stage reconstruction.

Bone height
achieved by Amount of Number of
Patient Etiology Location bone graft (mm) distraction (mm)a implants Survival of implants Follow-up (years)
LN Tumor resection Right mandible 6 14 5 4 4
(1 failure 6 months
post-insertion)
AN Tumor resection Right and anterior 7 14 5 5 6
mandible
KR Gun shot Left mandible 6 14 5 5 5
BI Gun shot Anterior maxilla 6 13 5 5 6
AI Tumor resection Bilateral mandible 7 13 6 6 5
BB Trauma Anterior maxilla 6 14 3 2 3
(1 failure 6 months
post-insertion)
BG Trauma Left mandible 6 14 3 3 5
SG Gun shot Anterior maxilla 7 13 3 3 4
ST Trauma Anterior maxilla 7 14 4 4 2
VT Bone atrophy Right mandible 6 14 4 4 3
following implant
failure
SS Trauma Left maxilla 6 14 2 2 6
UA Bone atrophy Bilateral mandible 7 13 5 5 10
EM Tumor resection Anterior maxilla 7 14 2 2 4
a
Amount of distraction (not including bone graft height) following the consolidation period.

Please cite this article in press as: Rachmiel A, et al. Two-stage reconstruction of the severely deficient alveolar ridge: bone graft
followed by alveolar distraction osteogenesis, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.07.007
YIJOM-3752; No of Pages 8

Two-stage reconstruction of the alveolar ridge 5

Table 3. Life-table analysis showing the cumulative implant survival rate.

Time interval (years) Implants at interval start Failures during interval Survival rate for interval (%) Cumulative survival rate (%)
0–1 52 2 96.15 96.15
1–2 50 0 100 96.15
2–3 46 0 100 96.15

height in the deficient area, allows an rigidity and also the need to control the control and stabilize the direction of elon-
osteotomy and placement of distractors vector of lengthening11,12. The vector of gation during the active phase10,31,32.
to be performed in a second stage. In this elongation is very important in DO, and Thus, it is important to be aware of the
manner, a total newly created bone height several methods have been applied to vector of distraction, the stability of the
of at least 20 mm can be achieved (onlay
bone graft + ADO).
Ilizarov stressed the importance of dis-
traction device stability as opposed to

Fig. 7. Following elongation of the transport Fig. 9. Facial appearance following bony and prosthetic rehabilitation: clinical photographs
segment: (A) panoramic X-ray at the end of obtained (A) before and (B) after the two-stage augmentation technique. Note the newly gained
the elongation stage; note the temporary an- bony and dental support to the lower lip.
chorage devices used to control the vector of
elongation; (B) cone beam computed tomog-
raphy following device removal.

Fig. 8. Implant placement in the newly cre-

ated bone: (A) panoramic X-ray following the
placement of six dental implants in the newly
created bone; (B) clinical photograph of the
prosthetic rehabilitation; note the bony sup- Fig. 10. Severe alveolar bone deficiency following ablative surgery: (A) panoramic X-ray and
port and keratinized tissue around the dental (B) computed tomography showing a severe alveolar bone defect in the anterior left maxilla; (C)
implants. intraoral clinical photograph showing the deficiency.

Please cite this article in press as: Rachmiel A, et al. Two-stage reconstruction of the severely deficient alveolar ridge: bone graft
followed by alveolar distraction osteogenesis, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.07.007
YIJOM-3752; No of Pages 8

6 Rachmiel et al.

Fig. 11. First stage of augmentation using an

onlay bone graft: (A) panoramic X-ray and
(B) computed tomography following iliac
crest onlay bone grafting to the alveolar max-
illary defect.

bone, the final alveolar height, and the

timing of placement of dental implants.
When facing a large alveolar deficiency of
over four teeth, the use of two distraction
devices on both sides of the osteotomy
will assist in controlling the sagittal plane Fig. 12. Alveolar distraction osteogenesis at least 6 months following bone graft placement: (A)
of the vector of elongation. clinical photograph showing the osteotomy and fixation of the distractor device; (B) clinical
photograph following surgery and prior to the activation phase; (C) panoramic X-ray following
This article reports a two-stage treat- alveolar distractor placement and before the commencement of elongation.
ment protocol for patients with severe
atrophy: bone grafting as the first stage,
followed by DO in a second stage
(Fig. 15). It is important to stress that
the onlay bone graft should not be per-
formed during the treatment of the initial
trauma, but following soft tissue and bony
healing.
Following bone graft assimilation, an
additional mean distraction elongation of
13.7 mm was achieved in the patients
included in this study. All patients showed
good inter-maxillary vertical relationships
with adequate bone for the placement of
dental implants, thus resulting in a favor-
able implant to crown ratio. Over a mean
follow-up of 4.85 years, 96.15% of the
implants survived, a survival rate similar
to that seen for implants placed in non-
treated bone33,34. This can be explained by
the timing of dental implant placement,
which was performed approximately
1 year following the initial surgery:
6 months of onlay bone graft integration
(in which the major initial resorption
occurs) followed by the process of ADO
(in which new stable bone was generated). Fig. 13. Following elongation of the transport segment: (A) and (B) clinical photographs
Adell et al. reported a mean marginal bone following vertical elongation; (C) panoramic X-ray at the end of the elongation stage.
loss in dental implants of 1.5 mm during
the first year, followed by 0.1 mm/year greater bone lengthening than other meth- tion, the induction of bone morphogenetic
thereafter35. In this study, less than ods8. protein (BMP) is observed during me-
2 mm of marginal bone loss was observed When performing an onlay bone graft chanical traction, and a subsequent in-
in all implants. alone, resorption rates are high7,36. When crease in the recruitment, proliferation,
Advantages of ADO include simulta- utilizing ADO on the integrated bone graft and differentiation of stem cells is ob-
neous expansion of both bone and soft together with the native basal bone, the served15. The use of BMP during distrac-
tissue, no donor site morbidity as com- increased blood flow facilitates the induc- tion can enhance bone formation39. It has
pared to autogenous block bone grafts, and tion of bone regeneration15,37,38. In addi- been demonstrated by the present authors’

Please cite this article in press as: Rachmiel A, et al. Two-stage reconstruction of the severely deficient alveolar ridge: bone graft
followed by alveolar distraction osteogenesis, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.07.007
YIJOM-3752; No of Pages 8

Two-stage reconstruction of the alveolar ridge 7

could inappropriately have influenced

their actions.

Ethical approval
This study followed the Declaration of
Helsinki on medical protocol and ethics
and was approved by the institutional
ethics review board.

Patient consent
Patient consent was obtained to publish
the clinical photographs.

Fig. 14. Implant placement in the newly created bone: (A) panoramic X-ray following the
placement of two dental implants in the newly created bone; (B) clinical photograph of the References
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Please cite this article in press as: Rachmiel A, et al. Two-stage reconstruction of the severely deficient alveolar ridge: bone graft
followed by alveolar distraction osteogenesis, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.07.007
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Address:
Dekel Shilo
Rambam Health Care Campus
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Haifa 35254
Israel
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E-mail: dekelshi@yahoo.com