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Alveolar distraction osteogenesis of bone graft reconstructed mandible
Alveolar distraction osteogenesis of bone graft reconstructed mandible _ Alper Alkan, DDS, PhD,a Burcu Basx, DDS,b and Samet Inal, DDS,c Samsun, Turkey DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, DENTAL FACULTY, ONDOKUZ MAYIS UNIVERSITY
This case report describes a patient who had severe mandibular bony deficiency as a result of excision of aggressive central giant cell granuloma. The defect was reconstructed with iliac bone graft. Four years later vertical distraction osteogenesis was performed on the grafted mandible in order to obtain a satisfactory bony height of mandibular ridge. Distraction osteogenesis can be a good alternative for the reconstruction of mandibular deficiencies. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:E39-42)
Reconstructing alveolar bone in patients with severe mandibular defects can be difficult. The methods that are currently used include guided bone regeneration, augmentation procedures, and distraction osteogenesis.1 A multitude of grafting techniques are available for functional and esthetic rehabilitation, including autografts, allografts, and xenografts. Autogenous bone grafting is the most widely used technique for reconstruction of the mandible.2 However, published success rates for mandibular bone graft reconstruction range from 38% to 100%.3 The main disadvantages of bone grafting are morbidity and the resorption of large amount of bone. Over the past 10 years, distraction osteogenesis has become increasingly popular and has been applied to maxillofacial region. The alveolar distraction technique appears to produce more rapid, predictable, and permanent outcomes compared with other regeneration techniques, according to initial reports of its clinical application.4 Distraction osteogenesis can be applied as a first-choice solution to restore vertical mandibular deficiency due to previous resections, atrophies, or trauma, or it can be used as a secondary treatment for the patients who have already undergone primary treatment for bone height restoration with inadequate results.5 In this case report we describe a patient who had a severe mandibular bony deficiency as a result of excision of aggressive central giant cell granuloma (CGCG) in which distraction osteogenesis techniques were used to improve the alveolar ridge vertical dimension. a
Head and Associate Professor, Department of Oral and Maxillofacial Surgery, Dental Faculty, Ondokuz Mayis University. b Research Assistant. c Research Assistant. Received for publication Jan 4, 2005; returned for revision Apr 19, 2005; accepted for publication Apr 25, 2005. 1079-2104/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.04.014
CASE REPORT A 9-year-old female patient was referred to our clinic with a complaint of mobility of the mandibular incisors and swelling of the adjacent vestibular mucosa. Radiographs revealed a well defined radiolucent area at the mandibular symphysis extending from the left canine to the right permanent first molar tooth. Lesion was associated with permanent tooth germs and the affected tooth roots were partially resorbed. There was only a thin layer of mandibular basal bone (Fig 1, A). A diagnosis of CGCG was made on clinical and radiologic bases; a biopsy was performed. The histologic appearance was typical of a CGCG. The patient was evaluated for hyperparathyroidism (serum calcium, phosphate, parathormone, and alkaline phosphatase levels), and possibility of brown tumor was excluded. The first operation was performed under general anesthesia via an intraoral approach. The lesion was aggressively curretaged. There was only a thin layer of cortical bone left at the lower border of the mandible and no intact bone at the vestibule and lingual cortex. An iliac corticocancellous bone graft was harvested from the iliac crest and fixed to the basal bone with a reconstruction plate (Fig 1, B). The patient was regularly seen until healing was complete. The plate was removed 1 year later and the patient followed up both clinically and radiographically for 4 years. Four years later, significant resorption of the grafted bone was observed (Fig 1, C and D). Bone height of the anterior mandible was considered insufficient to perform a functional and esthetic rehabilitation. Vertical distraction osteogenesis was planned to obtain satisfactory bony height of the mandibular ridge. Under general anesthesia, the intraoral bidirectional vertical distraction device (Modus ARS 1.5; Medartis, Basel, Switzerland) was placed. A horizontal incision was made in the buccal vestibule mucosa to expose the basal bone. A boxshaped osteotomy was done to the basal bone using surgical burs, oscillating saw, and osteotomes. After the bone segments were mobilized, the distractor was placed and flap was closed primarily (Fig 2). The distraction protocol included 7 days of latency after surgery and a distraction rate of 1 mm per day. The bone was distracted by about 13 mm (Fig 3, A and B). The follow-up included monthly clinical evaluation and panoramic and lateral cephalometric radiographs. Three months later the
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_ E40 Alkan, Basx, and Inal
Fig 1. A, Pretreatment radiograph shows an irregular radiolucent area at the mandibular symphysis associated with permanent tooth germs. B, Intraoperative photograph of the grafted bone after curettage of the lesion. C, Radiologic and D, clinical views of the bone remodeling after 4 years.
Fig 2. Intraoperative photographs showing the stages of the vertical alveolar distraction (A-D).
distractor was removed under local anesthesia (Fig 3, C and D). We are planning further prosthetic rehabilitation by dental implants.
DISCUSSION For reconstructing alveolar bone in patients with severe mandibular defects the methods currently used
include autogenous bone grafting, guided bone regeneration (GBR), and allogenic and alloplastic materials. Relatively small alveolar defects can be augmented by GBR,6 but it is not appropriate for larger defects, as in our case. Allogenic bone is the most commonly used alternative to the autogenous harvest, but it offers the potential risk of disease transmission, rejection, and resorption.7
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Fig 3. A, Before the distraction. B, Completion of the distraction. C, Evidence of new bone formation at device removal. D, Six months after distraction.
When autogenous bone graft is used, bone resorption must be expected. Various surgical techniques have been developed in an attempt to lessen the amount of bone resorption. For example, interpositional grafts and the visor osteotomy were tried but later abandoned owing to continued problems with graft resorption and concerns about neurosensory alterations secondary to the procedure.8,9 Onlay grafts were reported to lose 25%-33% of vertical height during the first 6 months.10 We used free bone graft at the initial operation. There was a large amount of resorption, as we expected, and insufficient bone to support dental implants 1 year following the grafting procedure. Vertical distraction osteogenesis was planned to restore mandibular height. Another treatment choice was regrafting with autogenous bone, but, because of its resorption tendency and morbidity of a second donor site, distraction was chosen. Distraction osteogenesis is the biologic process of new bone formation between bone segments gradually separated by incremental traction. Clinical experience with osteodistraction for alveolar ridge augmentation was initially reported by Chin and Toth,11 and has since been used sparingly by others.4,12 It has many advantages compared with onlay graft, using autogenous bone or allogenic materials, and GBR from the aspect of bone quality, bone quantity, and donor site morbidity.12,13 The main disadvantages of this technique include mispositioning of the distracted segment, bleeding in the osteotomy, painful tension when the distraction amount is larger than 10 mm, segment breakage during
large movements of thin alveolus, and difficulties during the adaptation of microplates.14 None of these complications was observed in our patients. Nocini et al5 performed vertical distraction osteogenesis on the grafted mandible in order to obtain a satisfactory height of the mandibular ridge. They performed the distraction osteogenesis 3 months after the grafting procedure. Before the distraction we planned to watch the resorption and remodeling for a period of at least 12 months. In our case, we waited 4 years owing to other problems with this patient. Distraction osteogenesis can also be applied to the basal bone when no alveolar bone remains. Uckan et al15 reported successful results of 3 patients in which more than 10 mm of distraction of mandibular basal bone was required. Because there was only a thin layer of basal bone at the lower border of the mandible (\10 mm) and a high risk of fracture, we did not consider the distraction at the first operation. Distraction osteogenesis can be considered to be a surgical technique both suitable and reliable for secondary treatment of patients who have already undergone primary treatment for bone height restoration with unsatisfactory results. REFERENCES 1. Triplett RG, Schow SR. Autologous bone grafts and endosseous implants: complementary techniques. J Oral Maxillofac Surg 1996;54:486-94. 2. August M, Tompach P, Chang Y, Kaban L. Factors influencing the long-term outcome of mandibular reconstruction. J Oral Maxillofac Surg 2000;58:731-7.
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_ E42 Alkan, Basx, and Inal 3. Adamo AK, Szal RL. Timing, results and complications of mandibular reconstructive surgery. J Oral Surg 1979;37:755-63. 4. Gaggl A, Schultes G, Karcher H. Vertical alveolar ridge distraction with prosthetic treatable distractors: a clinical investigation. Int J Oral Maxillofac Implants 2000;15:701-10. 5. Nocini FP, Albanese M, Prato EB, D’Agostino A. Vertical distraction osteogenesis of the mandible applied to an iliac crest graft: report of a case. Clin Oral Impl Res 2004;15:366-70. 6. Caplanis N, Sigurdsson TJ, Rohrer MD, Wikesjo UM. Effect of allogeneic, freeze-dried, demineralised bone matrix on guided bone regeneration in supraalveolar peri-implant defects in dogs. Int J Oral Maxillofac Implants 1997;12:634-42. 7. Moghadam H, Sandor G, Holmes H, Clokie C. Histomorphometric evaluation of bone regeneration using allogenic and alloplastik bone substitutes. J Oral Maxillofac Surg 2004;62: 202-13. 8. Stoelinga PJ, de Koomen JA, Tideman H, et al. A reappraisal of the interposed bone graft augmentation of the atrophic mandible. J Maxillofac Surg 1983;11:107-12. 9. Harle F. Long-term results with the visor osteotomy. Int J Oral Surg 1981;10(Suppl 1):83-7. 10. Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A. Staged reconstruction of the severely atrophic mandible with autogenous bone graft and endosteal implants. J Oral Maxillofac Surg 2002;60:1135-41.
11. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices: review of five cases. J Oral Maxillofac Surg 1996;54:45-53. 12. Block MS, Chang A, Crawford C. Mandibular alveolar ridge augmentation in the dog using distraction osteogenesis. J Oral Maxillofac Surg 1996;54:309-14. 13. Urbani G. Alveolar distraction before implantation: a report of five cases and a review of the literature. Int J Periodontics Restorative Dent 2001;21:569-79. 14. Uckan S, Haydar SG, Dolanmaz D. Alveolar distraction: analysis of 10 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:561-5. 15. Uckan S, Dolanmaz D, Kalaycı A, Cilasun U. Distraction osteogenesis of basal mandibular bone for reconstruction of the alveoler ridge. Br J Oral Maxillofac Surg 2002;40:393-6. Reprint requests: Dr Alper Alkan Disx Hekimlig˘i Faku¨ltesi Ondokuz Mayıs Universitesi 55139, Kurupelit Samsun, Turkey [email protected]
This case report describes a patient who had severe mandibular bony deficiency as a result of excision of aggressive central giant cell granuloma. The defect was reconstructed with iliac bone graft. Four years later vertical distraction osteogenesis was performed on the grafted mandible in order to obtain a satisfactory bony height of mandibular ridge. Distraction osteogenesis can be a good alternative for the reconstruction of mandibular deficiencies. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:E39-42)
Reconstructing alveolar bone in patients with severe mandibular defects can be difficult. The methods that are currently used include guided bone regeneration, augmentation procedures, and distraction osteogenesis.1 A multitude of grafting techniques are available for functional and esthetic rehabilitation, including autografts, allografts, and xenografts. Autogenous bone grafting is the most widely used technique for reconstruction of the mandible.2 However, published success rates for mandibular bone graft reconstruction range from 38% to 100%.3 The main disadvantages of bone grafting are morbidity and the resorption of large amount of bone. Over the past 10 years, distraction osteogenesis has become increasingly popular and has been applied to maxillofacial region. The alveolar distraction technique appears to produce more rapid, predictable, and permanent outcomes compared with other regeneration techniques, according to initial reports of its clinical application.4 Distraction osteogenesis can be applied as a first-choice solution to restore vertical mandibular deficiency due to previous resections, atrophies, or trauma, or it can be used as a secondary treatment for the patients who have already undergone primary treatment for bone height restoration with inadequate results.5 In this case report we describe a patient who had a severe mandibular bony deficiency as a result of excision of aggressive central giant cell granuloma (CGCG) in which distraction osteogenesis techniques were used to improve the alveolar ridge vertical dimension. a
Head and Associate Professor, Department of Oral and Maxillofacial Surgery, Dental Faculty, Ondokuz Mayis University. b Research Assistant. c Research Assistant. Received for publication Jan 4, 2005; returned for revision Apr 19, 2005; accepted for publication Apr 25, 2005. 1079-2104/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.04.014
CASE REPORT A 9-year-old female patient was referred to our clinic with a complaint of mobility of the mandibular incisors and swelling of the adjacent vestibular mucosa. Radiographs revealed a well defined radiolucent area at the mandibular symphysis extending from the left canine to the right permanent first molar tooth. Lesion was associated with permanent tooth germs and the affected tooth roots were partially resorbed. There was only a thin layer of mandibular basal bone (Fig 1, A). A diagnosis of CGCG was made on clinical and radiologic bases; a biopsy was performed. The histologic appearance was typical of a CGCG. The patient was evaluated for hyperparathyroidism (serum calcium, phosphate, parathormone, and alkaline phosphatase levels), and possibility of brown tumor was excluded. The first operation was performed under general anesthesia via an intraoral approach. The lesion was aggressively curretaged. There was only a thin layer of cortical bone left at the lower border of the mandible and no intact bone at the vestibule and lingual cortex. An iliac corticocancellous bone graft was harvested from the iliac crest and fixed to the basal bone with a reconstruction plate (Fig 1, B). The patient was regularly seen until healing was complete. The plate was removed 1 year later and the patient followed up both clinically and radiographically for 4 years. Four years later, significant resorption of the grafted bone was observed (Fig 1, C and D). Bone height of the anterior mandible was considered insufficient to perform a functional and esthetic rehabilitation. Vertical distraction osteogenesis was planned to obtain satisfactory bony height of the mandibular ridge. Under general anesthesia, the intraoral bidirectional vertical distraction device (Modus ARS 1.5; Medartis, Basel, Switzerland) was placed. A horizontal incision was made in the buccal vestibule mucosa to expose the basal bone. A boxshaped osteotomy was done to the basal bone using surgical burs, oscillating saw, and osteotomes. After the bone segments were mobilized, the distractor was placed and flap was closed primarily (Fig 2). The distraction protocol included 7 days of latency after surgery and a distraction rate of 1 mm per day. The bone was distracted by about 13 mm (Fig 3, A and B). The follow-up included monthly clinical evaluation and panoramic and lateral cephalometric radiographs. Three months later the
E39
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_ E40 Alkan, Basx, and Inal
Fig 1. A, Pretreatment radiograph shows an irregular radiolucent area at the mandibular symphysis associated with permanent tooth germs. B, Intraoperative photograph of the grafted bone after curettage of the lesion. C, Radiologic and D, clinical views of the bone remodeling after 4 years.
Fig 2. Intraoperative photographs showing the stages of the vertical alveolar distraction (A-D).
distractor was removed under local anesthesia (Fig 3, C and D). We are planning further prosthetic rehabilitation by dental implants.
DISCUSSION For reconstructing alveolar bone in patients with severe mandibular defects the methods currently used
include autogenous bone grafting, guided bone regeneration (GBR), and allogenic and alloplastic materials. Relatively small alveolar defects can be augmented by GBR,6 but it is not appropriate for larger defects, as in our case. Allogenic bone is the most commonly used alternative to the autogenous harvest, but it offers the potential risk of disease transmission, rejection, and resorption.7
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Fig 3. A, Before the distraction. B, Completion of the distraction. C, Evidence of new bone formation at device removal. D, Six months after distraction.
When autogenous bone graft is used, bone resorption must be expected. Various surgical techniques have been developed in an attempt to lessen the amount of bone resorption. For example, interpositional grafts and the visor osteotomy were tried but later abandoned owing to continued problems with graft resorption and concerns about neurosensory alterations secondary to the procedure.8,9 Onlay grafts were reported to lose 25%-33% of vertical height during the first 6 months.10 We used free bone graft at the initial operation. There was a large amount of resorption, as we expected, and insufficient bone to support dental implants 1 year following the grafting procedure. Vertical distraction osteogenesis was planned to restore mandibular height. Another treatment choice was regrafting with autogenous bone, but, because of its resorption tendency and morbidity of a second donor site, distraction was chosen. Distraction osteogenesis is the biologic process of new bone formation between bone segments gradually separated by incremental traction. Clinical experience with osteodistraction for alveolar ridge augmentation was initially reported by Chin and Toth,11 and has since been used sparingly by others.4,12 It has many advantages compared with onlay graft, using autogenous bone or allogenic materials, and GBR from the aspect of bone quality, bone quantity, and donor site morbidity.12,13 The main disadvantages of this technique include mispositioning of the distracted segment, bleeding in the osteotomy, painful tension when the distraction amount is larger than 10 mm, segment breakage during
large movements of thin alveolus, and difficulties during the adaptation of microplates.14 None of these complications was observed in our patients. Nocini et al5 performed vertical distraction osteogenesis on the grafted mandible in order to obtain a satisfactory height of the mandibular ridge. They performed the distraction osteogenesis 3 months after the grafting procedure. Before the distraction we planned to watch the resorption and remodeling for a period of at least 12 months. In our case, we waited 4 years owing to other problems with this patient. Distraction osteogenesis can also be applied to the basal bone when no alveolar bone remains. Uckan et al15 reported successful results of 3 patients in which more than 10 mm of distraction of mandibular basal bone was required. Because there was only a thin layer of basal bone at the lower border of the mandible (\10 mm) and a high risk of fracture, we did not consider the distraction at the first operation. Distraction osteogenesis can be considered to be a surgical technique both suitable and reliable for secondary treatment of patients who have already undergone primary treatment for bone height restoration with unsatisfactory results. REFERENCES 1. Triplett RG, Schow SR. Autologous bone grafts and endosseous implants: complementary techniques. J Oral Maxillofac Surg 1996;54:486-94. 2. August M, Tompach P, Chang Y, Kaban L. Factors influencing the long-term outcome of mandibular reconstruction. J Oral Maxillofac Surg 2000;58:731-7.
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_ E42 Alkan, Basx, and Inal 3. Adamo AK, Szal RL. Timing, results and complications of mandibular reconstructive surgery. J Oral Surg 1979;37:755-63. 4. Gaggl A, Schultes G, Karcher H. Vertical alveolar ridge distraction with prosthetic treatable distractors: a clinical investigation. Int J Oral Maxillofac Implants 2000;15:701-10. 5. Nocini FP, Albanese M, Prato EB, D’Agostino A. Vertical distraction osteogenesis of the mandible applied to an iliac crest graft: report of a case. Clin Oral Impl Res 2004;15:366-70. 6. Caplanis N, Sigurdsson TJ, Rohrer MD, Wikesjo UM. Effect of allogeneic, freeze-dried, demineralised bone matrix on guided bone regeneration in supraalveolar peri-implant defects in dogs. Int J Oral Maxillofac Implants 1997;12:634-42. 7. Moghadam H, Sandor G, Holmes H, Clokie C. Histomorphometric evaluation of bone regeneration using allogenic and alloplastik bone substitutes. J Oral Maxillofac Surg 2004;62: 202-13. 8. Stoelinga PJ, de Koomen JA, Tideman H, et al. A reappraisal of the interposed bone graft augmentation of the atrophic mandible. J Maxillofac Surg 1983;11:107-12. 9. Harle F. Long-term results with the visor osteotomy. Int J Oral Surg 1981;10(Suppl 1):83-7. 10. Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A. Staged reconstruction of the severely atrophic mandible with autogenous bone graft and endosteal implants. J Oral Maxillofac Surg 2002;60:1135-41.
11. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices: review of five cases. J Oral Maxillofac Surg 1996;54:45-53. 12. Block MS, Chang A, Crawford C. Mandibular alveolar ridge augmentation in the dog using distraction osteogenesis. J Oral Maxillofac Surg 1996;54:309-14. 13. Urbani G. Alveolar distraction before implantation: a report of five cases and a review of the literature. Int J Periodontics Restorative Dent 2001;21:569-79. 14. Uckan S, Haydar SG, Dolanmaz D. Alveolar distraction: analysis of 10 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:561-5. 15. Uckan S, Dolanmaz D, Kalaycı A, Cilasun U. Distraction osteogenesis of basal mandibular bone for reconstruction of the alveoler ridge. Br J Oral Maxillofac Surg 2002;40:393-6. Reprint requests: Dr Alper Alkan Disx Hekimlig˘i Faku¨ltesi Ondokuz Mayıs Universitesi 55139, Kurupelit Samsun, Turkey [email protected]