HANNA GERBER

1
, JAN NIENARTOWICZ
1
, WOJCIECH PAWLAK
1
, ZDZISAW WONIAK
2
BiDirectional Distraction Osteogenesis
of the Alveolar Bone Preliminary Report
Dwukierunkowa osteogeneza dystrakcyjna wyrostka zbodoowego
doniesienie wstpne
1
Department of Maxillofacial Surgery University of Medicine, Wrocaw, Poland
2
Department of Pathological Anatomy University of Medicine, Wrocaw, Poland
Dent. Med. Probl. 2006, 43, 3, 447451
ISSN 1644387X
CLINICAL CASE
Copyright by Silesian Piasts University of Medicine in Wrocaw
and Polish Stomatological Association
Abstract
Alveolar bone traumatic loss is a big reconstructive problem. Trauma causes both loss of alveolar bone and soft
tissues of the area. The authors present new methods of alveolar bone process reconstruction with the use of bi
directional osteogenesis distraction. Bone deficiency regeneration is presented as a result of bidirectional distrac
tion performed with Medartis V2 distracting device which allows the control of distraction direction both vertical
ly and linguallylabially. Histology of alveolar bidirectional reconstruction is described. Advantages of bidirec
tional distraction in osseous and soft tissues problems treatment avoiding additional surgical intervention are
emphasized (Dent. Med. Probl. 2006, 43, 3, 447451).
Key words: alveolar bone traumatic loss, bidirectional distraction osteogenesis.
Streszczenie
Pourazowa utrata koci wyrostka zbodoowego jest powanym problemem rekonstrukcyjnym. Uraz powoduje utra
t zarwno koci wyrostka, jak i tkanek mikkich w tej okolicy. Autorzy przedstawiaj nowe metody odbudowy ko
ci wyrostka zbodoowego z wykorzystaniem dwukierunkowej osteogenazy dystrakcyjnej. Opisana regeneracja ko
stna jest wynikiem dwukierunkowej dystrakcji za pomoc dystraktora Medartis V2 pozwalajcego kontrolowa kie
runek dystrakcji zarwno pionowo, jak i jzykowowargowo. Przedstawiono dowd histologiczny dwukierunkowej
rekonstrukcji wyrostka. Naley podkreli zalet dwukierunkowej dystrakcji w leczeniu ubytkw kostnych i tkanek
mikkich w postaci uniknicia dodatkowego zabiegu chirurgicznego (Dent. Med. Probl. 2006, 43, 3, 447451).
Sowa kluczowe: pourazowa utrata koci wyrostka zbodoowego, dwukierunkowa osteogeneza dystrakcyjna.
Since the introduction of distraction osteogen
esis to reconstruct facial bone, alveolar process
osteogenesis has been regarded an alternative
method of osseous defects before patients sched
uled prosthetic rehabilitation. Bidirectional dis
traction osteogenesis is a course of alveolar
process new bone formation to correct both its
height and lingual and labial vector which is espe
cially important on planning further treatment with
intraosseous implants as the precise installation in
the bony base in the correct position is indispens
able [13].
A major problem in alveolar process distrac
tion is the tendency of osteotomy fragment to dis
locate palatally in the maxilla or lingually in the
mandible. Such a displacement direction is caused
by the fact that buccal periosteum is incised in
order to reach osteotomy required access whereas
lingual periosteum remains intact and its continu
ity is indispensable to provide appropriate supply
of the osteotomized bone fragment. Besides, lin
gual displacement is caused by thick and non elas
tic mucous membrane of the palate. In atrophic
mandible, it seems the result of muscles traction in
the oral cavity floor [47]. Conventional one
directional distractors allow bone reconstruction
only in vertical dimension. After using onedirec
tional device, initially selected distraction direc
tion cannot be corrected during the treatment
[810]. Hence, multi directional osseous distrac
tion is a significant progress in bone defects recon
struction. Since 2000, the trials had been made to
construct and use clinically bidirectional distrac
tion system. Bidirectional device is fixed to
vestibular surface of the mandible body with the
use of mini plates and screws. The device is com
posed of titanium and has two cylinders. One of
them is used for vertical distraction and the other
enables anteriorposterior dislocation of the bone
defect. In this way, angulation of maximum 40 is
possible. In vertical direction, one turn gives 0.25
mm distraction [4, 10].
The goal of the paper is presentation of the
possibility of mandibular alveolar process recon
struction with the use of bidirectional distracting
device.
Case Report
Female patient N.O. aged 26 (case history
No 801/04) was transported to the Maxillofacial
Surgery Dept. by an ambulance on 23.08.2004 at
3 a.m. from a road accident after previous skull CT
and neurosurgical consultation. Clinical examina
tion revealed: unconscious female patient, intratra
cheally intubated, left cheek injuries penetrating to
oral cavity, lacerated and bleeding wound of upper
lip, nasal dorsum skin wounds. Intraoral cavity
examination showed: scalped mandible body from
the left angle area to 45 tooth area, comminuted
fracture of the mandibular alveolar process with its
crushing and avulsion of teeth 44, 43, 42, 41, 31.
There were also open fracture of the mandible
body on the left side as well as break of the artic
ular process of the mandible on the right side,
breaking of teeth 12, 22, 21 crown, left and right
eyes haematoma, sutured and dressed wound of
the right forearm. The patient developed respirato
ry insufficiency due to the presence of clots in
intubation tube and dysrythmia was found. The
patency of intubation tube was restored and when
her general condition was put under control, the
patient was qualified to emergency surgery. Oral
cavity and face wounds were debrided under gen
eral anaesthesia. Mandible body underwent repo
sitioning and plate osteosinthesis. Mandibular
alveolar process in 4431 teeth area was dressed.
After the surgery, the patient was referred to the
Intensive Care Unit of Wrocaw University of
Medicine Hospital.
Having regained consciousness, the patient
underwent the procedure of dressing the condylar
process fracture with splints with intermaxillary
fixation and occlusion conditions reconstruction.
After several months, the patient was admitted to
The Maxillofacial Surgery Dept. (case history No
611/05) to undergo the treatment of traumatic alve
olar bone loss in mandible with the use of bidirec
tional distractor by Medartis (Figs. 1, 2). Under
general anaesthesia and intratracheal intubation, in
the oral cavity vestibule, after intraoral incision, the
plate previously used for mandibular body fracture
osteosynthesis was removed. Tooth 31 was extract
ed due to the root complete exposure. Then, in seg
ment 4432, marginal osteotomy of mandibular
alveolar process was performed. Osseous segment
5 mm high was formed and it was pedunculated on
mucous and periosteal flap (Fig. 3). The courses of
vertical osteotomies were 1 mm distant from adja
cent teeth and slightly convergent with horizontal
osteotomy. All osteotomies were performed with
a saw. Distracting device was adapted 15 mm and
fixed by screws (diameter 1.5 mm) on the bone
vestibular surface (Fig. 4). Steering cylinders were
introduced to the oral cavity and the distractor was
untwisted (Fig. 6). The whole was covered with
mucous and periostial flap (Fig. 7). Postopera
tively, antibiotics were administered for 5 days.
After 10 days (resting stage), the stitches were
removed and active distraction was started to be
H. GERBER et al. 448
Fig. 1. Photograph reveals post traumatic deficiency
of alveolar ridge and loss of teeth
Ryc. 1. Fotografia przedstawia deficyt koci wyrostka
zbodoowego oraz braki zbowe po urazie, a przed
zabiegiem dystrakcji
Fig. 2. Pantomographic Xray before distraction
Ryc. 2. RTG przed zabiegiem dystrakcji
continued at a rate 0.5 mm a day for 30 days. When
expected vertical height was achieved, gradual seg
ment inclination was performed until the angle of
15 was gained. Alveolar process bone reconstruc
tion of 15 mm was achieved and the chip was posi
tioned in vestibular direction (Fig. 8).
After 8 weeks, the distracting device was
removed in local anaesthesia. Simultaneously,
BiDirectional Distraction Osteogenesis 449
Fig. 3. Mucoperiosteal flap reflected and osteotomy
lines visible
Ryc. 3. Stan po wytworzeniu pata luzwkowookost
nowego. Przedstawiono linie osteotomijne
Fig. 4. Adaptation of distraction device
Ryc. 4. Dostosowanie dystraktora
Fig. 5. Mobilization of osteotomized segment
Ryc. 5. Mobilizacja odamu kostnego
Fig. 6. Activation of distraction device
Ryc. 6. Etap rozkrcenia dystraktora w celu uwidocz
nienia zaplanowanego efektu leczenia
Fig. 7. Mucoperiosteal flap sutured and vector control
cylinders visible
Ryc. 7. Stan po przykryciu dystraktora patem luzw
kowookostnowym (widoczny element regulujcy)
Fig. 8. Pantomographic Xray after distraction
Ryc. 8. RTG po ukoczeniu leczenia dystraktorem
newly reconstructed bone was harvested from the
distraction gap for histopathological examination.
Radiologically, the consolidation of new bone was
observed in the distraction gap after 6 weeks.
Discussion
Alveolar bone deficiency results from peri
odontal diseases, tumours, trauma or congenital
defects. At present, there are various opinions con
cerning indications for distraction or reconstruction
based on osseous materials or autogenous grafts. In
distractive osteotomy, osteotomized bone fragment
is lifted by distractive device. The required height
of osteotomized bone must be at least 45 mm and
the space for distractor fixation. If these conditions
cannot be met, bone graft reconstruction method is
preferable. Another factor which largely influences
the treatment method is the condition of mucous
membrane. In the cases of tooth loss resulting from
trauma or infection, the healing process often caus
es tension scar formation. If, then, bone grafts are
performed, there is often difficulty with covering
the transplant with mucosal soft tissue. After sutur
ing, mucous membrane, at the stitches site, under
goes increased tension and very often, wound
dehiscence occurs which can cause infection and
even graft loss [4, 11, 12].
Distraction osteogenesis method makes the
mucous membrane gradual stretching by the
movement of distracted bone segment.
Consequently, secondary mucous membrane
changes eliminate the need for additional soft tis
sue procedures [4, 12, 13]. Presented bidirectional
distraction system enables vertical distraction and
also allows the vector change in buccallabial
directions which seems very important on plan
ning further implant treatment. The above factors
suggest that bone segmental deficiency after teeth
loss is a good indication for bidirectional distrac
tion osteogenesis [4]. Histological examination of
a bone newly formed in bidirectional distraction
system. In unidirectional distraction osteogenesis,
lately developed bone in distraction gap area con
sists of rods which reveal parallel alignment. The
density of a newly formed bone is low and the
maturation process can take even months [4, 14,
15]. Authors own examinations show bone high
density of complex architecture. Numerous ce
mentum lines are indicative of the bone strong
remodelling activity and ongoing maturation
process (Fig. 9). This histopathological examina
tion result shows that bone favourable regenera
tion is the result of combination of vertical dis
traction and gradual anterior angulation of the
bone fragment.
H. GERBER et al. 450
Fig. 9. Histologic appearance of tissues harvested
from the distraction regenerate at 2 month of consoli
dation. Active osteoblasts are present on the surface of
thin, immature, woven bone (H&E 20 and right
lower corner H&E 200)
Ryc. 9. Obraz histologiczny tkanki pobranej z regene
ratu w drugim miesicu po zakoczeniu dystrakcji. Na
uwag zasuguj osteoblasty widoczne na powierzchni
cienkich niedojrzaych beleczek kostnych (H&E 20
i w prawym dolnym rogu H&E 200)
References
[1] MARTINEZITURRIAGA M. T., RUIZ C. C.: Maxillary sinus reconstruction with calvarium bone grafts and endosse
ous implants. J. Oral Maxillofac. Surg. 2004, 62, 344347.
[2] SAMANDRI M. H., YAGHMAEI M., EJLALI M., MOSHREF M., SAFFAR A. S.: Use of amnion as a graft material in ve
stibuloplasty: A preliminary report. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2004, 97, 574578.
[3] SUGAR A. W., THIELENS P., STAFFORD G. D., WILLINS M. J.: Augmentation of the atrophic maxillary alveolar ridge
with hydroxyapatite granules in a Vicryl (Polyglactin 910) knitted tube and simultaneous open vestibuloplasty. Br.
J. Oral Maxillofac. Surg. 1995, 33, 9397.
[4] GUTWALD R., SCHMELZEISTEN R.: Primplantologischer knochen aufbau beatrophertem oberriefer. Zahnrztl. Mitt.
1998, 21, 11.
[5] DOMINIAK M., ZAREMBA A., SKOKIEWICZ K., PYKA E., STPIE P.: Moliwoci pokrycia recesji dzisa powstaej po
chirurgicznoortodontycznym leczeniu zbw zatrzymanych opis przypadku. Dent. Med. Probl. 2002, 39, 323329.
[6] HRZELER M. B., ZUHR O., SCHENK G., SCHOBERER U., WACHTEL H., BOLZ W.: Osteogeneza dystrakcyjna: sposb
leczenia poprawiajcy podstawowe warunki dla uzupenie estetycznych na natychmiastowo osadzanych implan
tach zbowych. Opis przypadku. Quintes. Periodontologia Implanty 2002, 4, 313320.
[7] MCCARTHY C., PATEL R. R., WRAGG P. F., BROOK I. M.: Augmentacja zatoki szczkowej przeszczepem kostnym
w celu zachowania implantw stomatologicznych opis przypadku klinicznego. Quintes. Periodontologia Im
planty 2003, 4, 287292.
[8] GERBERLESZCZYSZYN H., PAWLAK W., UCZAK K.: Wykorzystanie wewntrzustnych dystraktorw kostnych w le
czeniu ubytkw zbowych wyrostka zbodoowego uchwy opis przypadku. Dent. Med. Probl. 2003, 40,
155157.
[9] WANGERIN K.: Distraction in mouth, jaw and facial surgery. Mund Kiefer Geischtschir. 2000, 4, Suppl 1,
S226S236.
[10] SINA UCKAN, SEDA GURSOY HAYDAR, DOGAN DOLANMAZ: Alveolar distraction: Analysis of 10 cases. Oral Surg.
Oral Med. Oral Pathol. Oral Radiol. Endod. 2002, 94, 561565.
[11] KOWALCZYK R., SPORNIAKTUTAK K., SILUK J.: Zastosowanie wewntrzustnych dystraktorw kostnych w leczeniu
wad rozwojowych uchwy doniesienie wstpne. Czas. Stomat. 2002, 55, 3641.
[12] ENGEL P. S., RAUCH D. M., LADOV M. J., PRECHEUR H. V., STERN R. K.: Alveolar distraction osteogenesis: a new
alternative to bone grafts. Report of three cases. J. N. J. Dent. Assoc. 1999; 70, 2021, 5657.
[13] CRAIG F., JOHN M., J. MOCHE: Distraction osteogenesis: use in mandibular and maxillary reconstruction. Curr.
Opin. Otolaryng. Head Neck Surg. 2002, 10, 256260.
[14] MARIO J., IMOLA A.: Craniofacial distraction osteogenesis. Curr. Opin. Otolaryng. Head Neck Surg. 2001, 9,
238248.
[15] TAVAKOLI K., WALSH W. R., BONAR F., SMART R., WULF S., POOLE M. D.: The role of latency in mandibular oste
odistraction. J. CranioMaxillofac. Surg. 1998, 26, 209219.
[16] GARCIA A. G., MARTIN M. S., VILA P. G., REY J. M. G.: A preliminary morphologic classification of the alveolar
ridge after distraction osteogenesis. J. Oral Maxillofac. Surg. 2004, 62, 563566.
[17] KLUG C. N., MILLESISCHOBEL G. A., MILLESI W., WATZINGER F., EWERS R.: Preprosthetic vertical distraction oste
ogenesis of the mandible using an lshaped osteotomy and titanium membrames for guided bone regeneration.
J. Oral Maxillofac. Surg. 2001, 59, 13021308.
[18] GARCIA A. G., MARTIN M. S., VILA P. G., SAULACIC N., REY J. M. G.: Alveolar distraction before insertion of den
tal implants in the posterior mandible. Br. J. Oral Maxillofac. Surg. 2003, 41, 376379.
Address for correspondence:
Jan Nienartowicz
Department of Maxillofacial Surgery
Silesian Piast University of Medicine in Wrocaw
Chaubiski 5
50368 Wrocaw
Poland
tel.: +48 071 748 22 61
email: nienartowicz@gmail.com
Received: 17.05.2006
Revised: 6.09.2006
Accepted: 6.09.2006
Praca wpyna do Redakcji: 17.05.2006 r.
Po recenzji: 6.09.2006 r.
Zaakceptowano do druku: 6.09.2006 r.
BiDirectional Distraction Osteogenesis 451