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J Oral Maxillofac Surg 60:496-501, 2002

Minor Complications Arising in Alveolar Distraction Osteogenesis


Abel Garcia Garcia, MD, PhD,* Manuel Somoza Martin, DDS, Pilar Gandara Vila, DDS, and Jacobo Lopez Maceiras, DDS
This study evaluates complications that arise during mandibular alveolar distraction osteogenesis and suggests treatments. Methods: We monitored complications that arose during alveolar distraction osteogenesis in 5 patients who underwent a total of 7 distractions, in all cases using an intraosseous distractor (Lead System, Leibinger, Germany). We report our responses to each type of complication. Results: All 7 distractions were followed by the placement of 2 implants. The restoration was ideal in 4 of the 7 cases and functional but not ideal in the remaining 3. In all 7 distractions, we observed complications, although many were minor complications readily avoided by the use of appropriate technique. The complications were, rst, intraoperative complications, namely 1) fracture of the transport segment (1 of 7 cases; Response: appropriate preventative measures), 2) difculties in nishing the osteotomy on the lingual side (7 of 7 cases; Response: use of ne chisels made from cement spatulas), and 3) excessive length of the threaded rod (1 of 7 cases; Response: cut the rod). Second, complications arose during distraction: 1) incorrect direction of distraction (2 of 7 cases; no corrective measures necessary in the present cases), 2) perforation of the mucosa by the transport segment (2 of 7 cases; response: smooth the crest of the segment with a bone rongeur), and 3) suture dehiscence (1 of 7 cases; no signicant implications). Third, there were postdistraction complications, namely bone formation defects (4 of 7 cases; response: guided bone regeneration). Conclusion: A number of complications may arise during alveolar distraction osteogenesis. Most of these complications can be considered minor and are readily avoided or resolved by the use of appropriate procedures. 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:496-501, 2002 Alveolar distraction osteogenesis is a recently introduced surgical technique that is rapidly gaining widespread acceptance. A number of distraction devices are commercially available. In general, these can be classied as juxtaosseous or intraosseous. Juxtaosseous distractors (eg, Distractor Track; KLS/Martin, Tuttlingen, Germany) are placed over the buccal surface of the jaw, whereas intraosseous distractors (eg, Lead System, Leibinger, Kalamazoo, MI; and DIS-SIS Distractionimplant; SIS Systems Trade GmbH, Klagenfurt, Austria) are placed through the transport segment in the direction of distraction. We used Lead System distractors because of their simplicity, their small size, and their low cost in comparison with juxtaosseous distractors. Lead System distractors are intraosseous distractors that consist of a threaded rod, a transport plate, and a base plate: the threaded rod transverses the transport segment from the alveolar margin to the distraction gap, where it screws into the transport plate, which in turn is screwed to the transport segment. Also in the gap, the tip of the threaded rod rests against the base plate, which is screwed into the basal bone. Turning the threaded rod separates the transport plate from the base plate, increasing the size of the gap.1 496
Purpose:

*Head of Section, Department of Maxillofacial Surgery, Complejo Hospitalario Universitario de Santiago and Professor of Maxillofacial Surgery, University of Santiago de Compostela, Santiago de Compostela, Spain. Assistant Professor, Oral Surgery Unit, School of Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain. Assistant Professor, Oral Surgery Unit, School of Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain. Postgraduate Student, Oral Surgery Unit, School of Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain. Address correspondence and reprint requests to Dr Garcia: Facultad de Odontologia, Entrerrios s/n, Santiago de Compostela, Spain; e-mail: ciabelgg@usc.es
2002 American Association of Oral and Maxillofacial Surgeons

0278-2391/02/6005-0004$35.00/0 doi:10.1053/joms.2002.31844

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Here we report a study of complications arising in 5 patients during osteotomy and subsequent distraction with a Lead System distractor, and we propose treatments for each type of complication.

Materials and Methods


SAMPLE

We studied 5 patients who had undergone a total of 7 mandibular alveolar distractions. In all cases, the distraction was performed using a Lead System distractor. Six of the 7 distractions were performed in the posterior mandible, and 1 was performed in the incisive-canine region.
SURGICAL TECHNIQUE

All patients were treated while under local anesthesia. A crestal incision was made along the alveolar ridge, and a vestibular mucoperiosteal ap was raised, maintaining the attachment of the lingual mucoperiosteum to the transport segment. The transport segment was cut to an inverted trapezoidal shape, so as not to interfere with mobility during distraction. Osteotomy was performed with rotary instruments (sidecutting burrs, discs, and reciprocating saws) and chisels. The transport segment was totally mobilized although remained attached to the lingual mucoperiosteum. The distractor (ie, threaded rod, transport plate, and base plate) was assembled and positioned according to the procedure of Chin1 (Fig 1). Once the distractor had been positioned, and without suturing the mucoperiosteal ap, the transport segment was immediately raised (ie, within the same surgical session) to a height of 5 mm to conrm adequate mobility and appropriate direction of movement and absence of interference between the transport segment and the basal bone. The transport segment was then returned to its original position. Distraction was commenced 7 days later at a rate of 0.5 mm every 12 hours for 5 days. After 12 weeks, the distractor was removed, and the implants were placed. At 14 weeks after implant placement, the prosthetic restoration was commenced and subjected to load. Restorations were subsequently classied as ideal, functional but not ideal, or nonfunctional. The complications that arose are considered in 3 groups: intraoperative complications, complications arising during distraction, and postdistraction complications.

FIGURE 1. Photograph showing placement of the Lead System distractor. A crestal incision is made along the alveolar ridge, and a vestibular mucoperiosteal ap is raised, maintaining the attachment of the lingual mucoperiosteum (B) to the transport segment (A) (C, basal bone). The distractor is then placed as shown: D, threaded rod; E, transport plate; and F, base plate.

placed in the distracted region (8 ITI 4.1 mm, 12.0 mm PLUS; Straumann, Waldenburg, Switzerland and 4 Frialoc D4/L13; Friadent, Mannheim, Germany). In all cases, a prosthetic restoration was subsequently performed. The restoration was ideal in 4 of the 7 cases and functional but not ideal in the remaining 3 cases. Complications are summarized in Table 1.
INTRAOPERATIVE COMPLICATIONS

Fracture of the Transport Segment This type of complication occurred in 1 case, due to an attempt to free the transport segment using a chisel. As a result, a small fragment of cortical bone was lost. Subsequent bone formation in the region of the lost fragment was decient. Difculties in Completing the Osteotomy on the Lingual Side In all 7 cases, difculties were encountered in completing the osteotomy on the lingual side, which we had to access from the labial vestibular side. To do this, we constructed ne chisels from cement spatulas (Fig 2), which we carefully introduced from the vestibular side, checking their exit from the lingual side with a nger so as to avoid damage to the lingual mucoperiosteum or the oor of the mouth. Excessive Length of the Threaded Rod In 1 case, the threaded rod may have interfered with occlusion. This complication can be predicted

Results
In all cases, bone formed in the regeneration chamber, and the transport segment was stable. Likewise, in all cases, 2 implants were subsequently successfully

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Table 1. COMPLICATIONS OF THE ALVEOLAR DISTRACTION

Patient No. 1

Complications Distraction Location


Intraoperative During Distraction Postdistraction

Implants Placed 2 ITI

Restoration Functional but not ideal

2 3

Left posterior Excessive length of the Incorrect mandibular region threaded rod direction of Fracture of the transport distraction segment Difculties in completing the osteotomy on the lingual side Left posterior Difculties in completing mandibular region the osteotomy on the lingual side Incisive-canine Difculties in completing Perforation of the mandibular region the osteotomy on the mucosa by the lingual side transport segment Suture dehiscence Left posterior Difculties in completing Perforation of the mandibular region the osteotomy on the mucosa by the lingual side transport segment Right posterior Difculties in completing mandibular region the osteotomy on the lingual side Left posterior Difculties in completing Incorrect mandibular region the osteotomy on the direction of lingual side distraction Right posterior Difculties in completing mandibular region the osteotomy on the lingual side

Bone formation defects

Bone formation defect

2 ITI 2 ITI

Ideal Ideal

Bone formation defect Bone formation defect

2 ITI

Ideal

2 ITI

Ideal

2 Frialoc Functional but not ideal 2 Frialoc Functional but not ideal

with the aid of articulator-mounted casts and is readily resolved by cutting the rod to the appropriate length before placement.
COMPLICATIONS DURING DISTRACTION

ulcer arose. Treatment involves elimination of the sharp edge with use of a burr or a rongeur. In both cases, the mucosa grew over the bone, without any need to interrupt the distraction. Suture Dehiscence This occurred in 1 case, leading to some exposure of the transport segment. There was no need to interrupt distraction, and the mucosa subsequently grew completely over the bone.
POSTDISTRACTION COMPLICATIONS

Incorrect Direction of Distraction This complication occurred twice, due to lingual deviation of the threaded rod. As a consequence, excessive bone formed in the lingual direction. In both cases, however, sufcient bone was obtained to t 12-mm implants. Perforation of the Mucosa by the Transport Segment This complication occurred twice, due to the sharp edges of the transport segment. In 1 case, a lingual

FIGURE 2. Osteotomes constructed from cement spatulas.

Bone Formation Defects Complications of this type arose in 4 cases. In 3 cases, bone formation was not uniform, giving rise to bone formation defects. In all cases, these defects led to incomplete coverage of the implant (dehiscence or fenestration). In 1 case (noted in section on fracture of the transport segment), the defect was a dehiscence defect due to loss of a fragment of the transport segment during osteotomy. In the other 2 cases, the defects were fenestration defects. Treatment was bone regeneration using Bio-Oss and Bio-Gide reabsorbable membranes (Geistlich Pharma AG, Wolhusen, Switzerland).

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499 segment should be sufcient to withstand the osteotomy maneuvers. Care should be taken in manipulation, and no attempt should be made to move the segment until the osteotomy is complete. With rotary instruments, it is easy to perform the osteotomy on the vestibular side, but the osteotomy on the lingual side is more difcult. To overcome this complication, we designed and constructed chisels from cement spatulas, allowing us to complete the osteotomy of the lingual cortex while respecting the integrity of the mucoperiosteum. Excessive length of the threaded rod, hindering proper occlusion, is a signicant problem, because the distractor must remain in the patients mouth for at least 14 weeks. However, presurgical planning with articulator-mounted casts should enable the problem to be predicted. In the case of Lead System distractors, the problem is readily solved, because the threaded rod can be cut without affecting its function. Inappropriate direction of distraction may be due to any of several factors. Generally, the distractor will tend to lean to the lingual side. The hole drilled for insertion of the threaded rod may be angled incorrectly. Either the base plate or the transport plate may not t correctly. The force exerted by the lingual periosteum attached to the transport segment may lead to inappropriate direction of distraction if not taken into account (Fig 3). To solve this complication,

Discussion
Since the 19th century, there have been numerous attempts to develop techniques to extend the long bones.2,3 Distraction osteogenesis of the long bones was pioneered by Ilizarov.4-6 More recently, distraction techniques have been applied to the facial bones and soft tissues,7-13 including use in the treatment of inadequate height of the alveolar ridge.14-19 Alveolar distraction osteogenesis promises to have very useful applications in the eld of implantology, particularly in cases of mandibular alveolar hypoplasia. In such cases, the lack of sufcient bone height between the alveolar canal and the alveolar rim means that the implant must be short; at the same time, the reduced height of the rim means that the crown must be long. By increasing the height of the alveolar rim, alveolar distraction osteogenesis overcomes both problems. An understanding of the potential complications of a given surgical technique, and of appropriate treatments, is fundamental for correct implementation of that technique. In the present study, we therefore evaluated complications arising in 7 alveolar distractions, all performed with Lead System distractors (Table 2). Fracture of the transport segment during osteotomy is a complication that can be avoided only by preventative measures. The thickness of the transport

Table 2. TREATMENT AND CONSEQUENCES OF THE COMPLICATIONS OF ALVEOLAR DISTRACTION

Complications Intraoperative Fracture of the transport segment Difculties in completing the osteotomy on the lingual side Excessive length of the threaded rod During distraction Incorrect direction of distraction

Treatment Appropriate preventative measures Use of appropriate instruments Cut the rod Care in positioning the distractor at the correct angle Take into account the effect of the lingual mucoperiosteum Use of orthodontic devices (Chin1) Smooth the extremes of the segment with a burr or rongeur No action usually required; closure by second intention

Consequences Absence of bone formation Extended surgery time If not corrected, interference with occlusion Bone formation in the wrong direction

Perforation of the mucosa by the transport segment Suture dehiscence Breakage or loss of the distractor (MillesiSchobel et al,21 Gaggl et al22) Post distraction Bone formation defects

Lingual ulcer No sequelae observed

Guided bone regeneration Application of a titanium membrane during the osteotomy (Klug et al20)

Gaps in the bone around the implant

Other Dysesthesia of the mental nerve (Klug et al,20 Gaggl et al,22 Nocini et al23)

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FIGURE 3. Diagram showing the tension exerted by the lingual mucoperiosteum (C) on the transport segment, leading if not corrected to distraction direction (B) as opposed to the desired distraction direction (A).

Chin1 proposed the use of an orthodontic appliance to guide the threaded rod. However, this requires that the edentulous space should have teeth at both extremes, which was not the case in either of the subjects who had this complication in the present study. When the distractor is assembled and positioned, it is thus important to bear in mind the forces exerted by the lingual mucoperiosteum attached to the segment and to angle the threaded rod slightly outward to compensate for this force during distraction. Perforation of the mucosa by the sharp edges of the transport segment is typically observed as the distraction proceeds. Elimination of the sharp edges allows rapid growth of the mucosa over the bone, in contrast to the situation expected with a free bone graft. This complication does not require interruption of the distraction procedure. Suture dehiscence was observed in a single case and did not constitute a problem; indeed, it was not even necessary to interrupt the distraction procedure. The transport segment is vascularized, so epithelium grows normally over it. Normal epithelium growth does not occur with free bone grafts. This complication may lead to loss of the graft. Bone formation defects were observed in 3 cases. In 1 case, the defect was a dehiscence defect due to the loss of a fragment of bone from the transport segment during the osteotomy. In the other 2 cases (both fenestration defects), there was no evident explanation for the defect observed. All of these defects were successfully treated with Bio-Oss covered with a Bio-Gide membrane. Klug et al20 proposed that complications of this type can be avoided by tting a titanium membrane over the defect immediately after osteotomy, to avoid invasion by connective tissue.

However, this technique may give rise to further complications, such as exposure of the titanium membrane. In no case did we observe complications that involved the inferior dental nerve, which are to be expected in particular during osteotomy. Such complications are especially likely if the mandible is highly atrophic. Millesi-Schobel et al21 reported a case of fracture of the distractor during mandibular alveolar distraction in a patient in whom a juxtaosseous-type distractor was used. In reports presented at the XVth Congress of the European Association for CranioMaxillofacial Surgery in Edinburgh in September 5 through 9, 2000, Klug et al,20 Gaggl et al,22 and Nocini et al,23 mention other complications, such as dysesthesia of the mental nerve and mandibular fracture. In addition, Gaggl et al,22 reported loss of the implant in a patient in whom a DIS-SIS distraction implant (SIS Systems Trade GmbH) was used. We have not observed any of these complications. In view of our results and our review of the literature, it may appear that complications are unacceptably frequent in this procedure. However, it should be stressed that the complications that arose can all be considered minor and in all cases had simple solutions; in no case did the complications cause the technique to fail or reduce the rate of distraction.

References
1. Chin M: Distraction osteogenesis for dental implants. Atlas Oral Maxillofac Clin North Am 7:41, 1999 2. Bertram CH, Nielander KH, Konig DP: Pioniere der Extremitat enverlangerung. Chirurg 70:1374, 1999 3. Codivilla A: On the means of lengthening in the lower limbs, the muscles and tissues which are shortened through deformity. Am J Orthop Surg 2:353, 1905 4. Green SA: Ilizarov method. Clin Orthop 280:2, 1992 5. Ilizarov GA: The tension-stress effect on the genesis and growth of tissues, part I: The inuence of stability of xation and soft tissues preservation. Clin Orthop 238:249, 1989 6. Ilizarov GA: The tension-stress effect on the genesis and growth of tissues, part II: The inuence of the rate of frequency of distraction. Clin Orthop 239:263, 1989 7. Snyder CC, Levine GA, Swanson HM, et al: Mandibular lengthening by gradual distraction: A preliminary report. Plast Reconstr Surg 51:506, 1973 8. Michieli S, Miotti B: Lengthening of mandibular body by gradual surgical-orthodontic distraction. J Oral Surg 35:187, 1977 9. Karp NS, Thorne CHM, McCarthy JG, et al: Bone lengthening in the craniofacial skeleton. Ann Plast Surg 24:231, 1990 10. Karp NS, McCarthy JG, Schreiber JS, et al: Membranous bone lengthening: A serial histological study. Ann Plast Surg 29:2, 1992 11. McCarthy JG, Schreider J, Karp N, et al: Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 89:1, 1992 12. Molina F, Ortiz Monasterio F: Mandibular elongation and remodeling by distraction: A farewell to major osteotomies. Plast Reconstr Surg 96:825, 1995

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13. Chin M, Toth BA: Distraction osteogenesis in maxillofacial surgery using internal devices: Review of ve cases. J Oral Maxillofac Surg 54:45, 1996 14. Block MS, Chang A, Crawford C: Mandibular alveolar ridge augmentation in the dog using distraction osteogenesis. J Oral Maxillofac Surg 54:309, 1996 15. Klein C, Papageorge M, Kovacs A, et al: Erste Erfahrungen mit einem neuen Distraktionsimplantatsystem zur Kieferkammaugmentation. Mund Kiefer Gesichtschir 3:S74, 1999 (suppl 1) 16. Oda T, Sawaki Y, Ueda M: Alveolar ridge augmentation by distraction osteogenesis using titanium implants: An experimental study. Int J Oral Maxillofac Surg 28:151, 1999 17. Gaggl A, Schultes G, Karcher H: Distraction implants: A new operative technique for alveolar ridge augmentation. J Craniomaxillofac Surg 27:214, 1999 18. Hidding J, Lazar F, Zoller JE: Erste Ergebnisse bei der vertikalen

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Distraktionsosteogenese des atrophischen Alveolarkamms. Mund Kiefer Gesichtschir 3:S79, 1999 (suppl 1) Chin M: Distraction osteogenesis in maxillofacial surgery, in Lynch SE, Genco RJ, Marx RE (eds): Tissue Engineering. Chicago, IL, Quintessence Books, 1999, pp 147-159 Klug C, Millesi G, Millesi W, et al: Vertical callus distraction for mandibular augmentation: L-Shaped osteotomy and GBR by titanium membranes. J Craniomaxillofac Surg 28:55, 2000 (suppl 3) Millesi-Schobel GA, Millesi W, Glaser C, et al: The L-shaped osteotomy for vertical callus distraction in the molar region of the mandible: A technical note. J Craniomaxillofac Surg 28:176, 2000 Gaggl A, Schultes G, Karcher H: Distraction implants in alveolar ridge aumentation: A 2-year follow-up. J Craniomaxillofac Surg 28:101, 2000 (suppl 3) Nocini PF, Wangerin K, Cortelazzi R, et al: Distraction osteogenesis in preprosthetic surgery. J Craniomaxillofac Surg 28: 100, 2000 (suppl 3)

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