Bone grafting techniques in the atrophic posterior mandible anatomical site are very difficult to manage. The inlay technique, even if successful,1–9 is technically demanding.10 The onlay technique is easier and has greater flexibility in approaching defects with complex morphologies10–12 but is affected by a huge resorption of the graft.10 Guided bone regeneration resulted an operator-dependent technique,13 limited to the treatment of small edentulous segments with appropriate morphology,11,14 and is affected by frequent membrane exposure and bacterial contamination.15–18 The use of titanium meshes with particulate bone, albeit useful,19–22 has presented a considerable risk of soft tissues dehiscence.22–25
As an alternative to grafting procedures, the transposition of the mandibular nerve may affect the bundle integrity,10,26,27 and the use of short and/or narrow implants, even with promising outcomes,28–31 has, to date, a too short follow-up for drawing a definitive positive judgment.32–34
Alveolar distraction osteogenesis (DO) avoids bone harvesting and obtains simultaneous regeneration of mature bone and soft tissues.5,35–37 This technique has been effective even in the posterior atrophic mandible but was prone to a huge number of complications and failures.5,35,38–40 In this anatomical site, the presence of the inferior alveolar nerve, the high pull by mouth floor muscles, occlusal disturbances, and the scarcity of keratinized gingiva may jeopardize the final result.5,41,42 Furthermore, the technique is not always well accepted by the patient, and a failure may compromise definitively the treated site, with no further chances of treatment. These reasons have considerably reduced the indication for alveolar DO, preferred in case of a great hard and soft tissues loss for trauma or tumors,5,42,43 and performed by very experienced operators.22
To take advantage of this promising procedure, many variations have been applied by different authors to the distraction protocol using different types of distractors.22,44,45
Unlike the extraosseous devices, applied on the buccal surface of the bone portion, the intraosseous ones are placed through the upper transport segment and fixed to the basal segment toward the distraction vector. The intraosseous distractors are smaller than the extraosseous ones, allow a less-invasive surgical intervention for their placement limiting the periosteum detachment, and result more endurable for the patient.22,41 For these characteristics, they have been proposed for the distraction of the alveolar portion of the jaws.46–48
To shorten the treatment duration and to eliminate the problem of the distractor removal, the dental implant distractor (DID) was developed,49 coupling the distraction process with the surgical placement of the dental implant. The high risk of device fracture for the uneven distribution of stress and the lack of information about the long-term stability of these implants impeded their clinical use.35,49
The aim of this article is to put forth a case of an atrophic posterior mandible successfully rehabilitated with an implant-borne prosthesis after vertical bone augmentation with a new distraction protocol using a new intraosseous distraction device.
Materials and Methods
A 60-year-old systemically healthy woman was referred to our clinic for fixed prosthetic rehabilitation of her edentulous atrophic left posterior mandible. The patient had lost her first and second left mandibular molars about 10 years before without subsequent prosthetic rehabilitation. The resulting bone resorption had led to a lack of vertical bone volume in the 36-37 site with an increased interarch distance and scarcity of keratinized mucosa (Fig. 1). Preliminary radiographic evaluation (panoramic, intraoral radiographs, computed tomograms) and dental casts confirmed a Class V of mandibular partial atrophy according to the Cawood and Howell50 classification. In particular, the CT scans revealed a mean of residual bone height of ≤7 mm distal to the mental nerve foramen above the mandibular canal (Fig. 2). It was decided to obtain the adequate bone height for the placement of standard length implants with the DO procedure.
The distractor device used (Mozo-Grau S.L., Valladolid, Spain) has a 4-mm diameter and a total length of 6.4 mm and allows for a maximum of vertical augmentation of 6 mm, getting a total length of 12.4 mm. This device consists of 3 portion: an upper component, for the anchorage in the transport segment, sliding around an intermediate central screw, and a bottom component, fixed at the apical portion of the intermediate screw for the anchorage in the basal bone. Each part of the distractor is to be removed separately with 3 proper tools.
The surgical intervention for the application of the device was performed under local anesthesia (articaine [4%] and adrenaline [1:100,000]).
First, the soft tissues of the alveolar portion to be distracted were marked with a dental probe to evaluate their thickness and a portion of mucosa, and periosteum was removed with a circular scalpel (punch) only in correspondence of the planned location of the distractor, without raising any flap; thereafter, a full-thickness horizontal incision just below the mucogingival line was performed, and a limited surface of buccal bone was exposed, maintaining completely attached the soft tissues on the lingual and occlusal surface of the alveolar ridge. The horizontal osteotomy of the coronal transport segment was carried out using Piezo-surgery (Mectron Piezosurgery Device; Mectron, Carasco, Italy) to obtain a neat osteotomy line interesting the entire thickness of the alveolar process till the lingual surface had been reached, taking care of not damaging the lingual periosteum; the osteotomy line was localized at 3 mm from the crestal ridge with a guiding position marker that was calibrated considering the calculated thickness of mucosa and periosteum (Fig. 3). The distractor location was prepared before the osteotomy of the transport segment had been completed, with the use of serial burs according to the instructions of the productor; after the mesial oblique osteotomy had been carried out from the crestal ridge to the osteotomy line (Fig. 4), the distractor was inserted with a round-reduction hand-piece, and, thereafter, the osteotomy of the transport segment was completed with performing the second distal oblique osteotomy (Fig. 5). The osteotomized segment was immediately moved by activating the device to check the direction of distraction and freedom in movements, and, finally, it was repositioned at its initial position, and the surgical access was sutured with 4-0 Vicryl sutures (Ethicon FS-2; Ethicon, Brussels, Belgium).
The postoperative regimen included amoxicillin plus clavulanic acid, 1 g every 12 hours for 6 days; ibuprofen, 600 mg every 8 hours for 4 to 5 days; and 0.2% chlorhexidine mouth rinses every 12 hours for 1 week. The patient was instructed to avoid brushing and trauma to the surgical site and to maintain a soft food diet for 1 week.
After a waiting period of 10 days (latency), sutures were removed, and the activation of the distractor was started: a daily rate of distraction of 0.18 mm (a quarter of turn) was applied for 16 days to raise the transport segment for the first 3 mm; thereafter, a daily rate of 0.37 mm (a half of turn) was applied for 8 days. The distraction device was then kept in position for 30 days (consolidation period) to obtain adequate maturation of the neocallus formed between the basal bone and the distracted segment (Fig. 6).
After the consolidation period (30 days), a CT cone beam examination was taken (Fig. 7).
Under local anesthesia, a new surgical approach was performed to remove the distractor and to place implants. First, a titanium screw-shaped implant, 10-mm long and 4.25-mm wide (Mozo-Grau Inhex Implants S.L.), was placed in the distal position, still maintaining the distractor in place; thereafter, each component of the distractor was removed separately with the apposite tool (Fig. 8), and the second titanium screw-shaped implant, 10 mm-long and 4.25-mm wide (Mozo-Grau Inhex Implants S.L.), was placed exactly in the location of the distractor, modifying the osteotomy with a final drill (Fig. 9).
Two grams of amoxicillin were administered preoperatively and then 1 g twice a day for 5 days. Ibuprofen (600 mg) was prescribed to be taken as required.
The fixtures were allowed to heal for 4 months for osseointegration before prosthetic rehabilitation was initiated. The implants were uncovered 3 months later; abutments were placed, and a screw-retained, acrylic-resin, temporary fixed prosthesis was affixed (Fig. 10) and maintained for 6 months until the insertion of a screw-retained definitive prosthesis.
No problem was encountered during all the phases of the distraction procedure that was well tolerated by the patient. The healing of the treated site proceeded uneventfully, and a CT cone beam evaluation at time of distractor removal revealed a mean of 5-mm bone augmentation in height (Fig. 7). This bone vertical augmentation allows for the placement of two 10-mm long fixtures.
No periimplant bone resorption or prosthetic complications had been noted at the time of definitive prosthesis connection.
The atrophic posterior mandible is a very difficult site to be treated with grafting procedures, not only because of the superficial positioning of the mandibular canal but also because of particular characteristics of the hard and soft tissues, which complicate the graft healing and facilitate its resorption.51,52 The residual bone in this site consists of a thick and compact cortical layer, which reduces the permeability to osteogenic elements such as microvessels and cells.21 The overlying soft tissues are not simple to manage to cover the graft, because of the scarcity of keratinized mucosa and the proximity of a thin mobile mucosa to the residual ridge,5,11,21,53 with difficulty in their advancement and a huge risk of dehiscence and infection.10 Furthermore, the soft tissues, if no adequately released, may press notably on the grafts, enhancing resorption.
Avoiding reconstructive procedures before implant placement12,30,31 implies prosthetic compromises with an unaesthetic high prosthetic superstructure and unusual loading distribution that might jeopardize the long-term success of the rehabilitation.
DO allows the body’s natural healing mechanisms to generate new bone35 associated to the concurrent lengthening and adaptation of the overlying soft tissues.5,35–37 DO appeared as the ideal approach in treating alveolar deficits37,54–56 in terms of quality and quantity of hard and soft tissues obtained, even in the premolar and molar region of the partially edentulous mandible, although few studies have investigated the application of DO in these sites exclusively.5,36,57–60
Nevertheless, this procedure was able to result in an excellent outcome. In the posterior mandible, for example, the reported range of bone height gained goes from 1.35 mm57 to 15 mm.38 Furthermore, the obtained bone height seemed to be subjected to a considerable resorption, which has been valuated in about 2 mm of bone loss, with the necessity to overcorrect the defect.36
Another reported drawback of the technique is the discomfort for the patient who has to tolerate the device in his mouth.5
Regardless, the implant success after a DO in posterior mandible seems to be superior than what has obtained in jaws reconstructed with grafting procedures, going from 93.7% after 30 months of loading5 to 100% after 24 months of loading.38 Recently, there was a report of 95.7% of success after a mean of 62 months of loading.36
The complications in DO procedure may be distinguished, according to Enislidis et al,42 as being major are fracture of the device, fracture of the transport segment or the basal bone, misdirection of the distraction vector needing a secondary surgery, and permanent damage to the alveolar nerve and minor (minor misdirection, acute mucosa inflammation, limited dehiscence of soft tissues, reduction of the obtained bone height, and transient postoperative paresthesia of the lower lip). Although several studies have reported no major complications with the application of DO in the posterior mandible,5,38,39,45,57 Enislidis et al42 recorded a 21.6% of these problems. Recently, a percentage of 11.5% and 51.1% of major and minor complications, respectively, has been reported.36 The majority of complications in literature consisted in misdirection of the distraction vector, with an incidence of 11% to 100%,36,42,61 fracture of the transport segment or of the basal bone, varying from 3% to 19%,36,42,61 and permanent damage to the alveolar nerve up to 28% of incidence.36
The majority of complications seems to occur during the application of the distractor and during the latency and distraction phases.5,62
In view of these considerations, it seems that the real effectiveness of this procedure is not clear yet and that many variables have to be focused. In particular of importance are the characteristics of the device, such as the dimensions and the mechanical properties, and the timing and modalities of its application and removal and of its working.
After the application of the distraction technique in the maxilloacial surgery by McCarthy et al,63 with the use of extraosseous devices, Chin and Toth46 proposed the distraction of the alveolar process with a transcrestal approach. The “intraosseous” device was smaller than the extraosseous one and more bearable by the patient. It appeared easier to be applied to the surgical site with a minimally invasive surgery, such as the procedure for a conventional dental implant insertion, sparing a consistent part of the soft tissues attachment on the buccal side of the alveolar process.44 Nevertheless, the periimplant marginal bone resorption levels did not result as good as expected,41,44 and the amount of complications seemed to be comparable with that with extraosseous devices.22 Even if no precise indication has been correlated to a particular type of distractor, it may be stated that, when the alveolar portion to be treated is long, with a transport segment longer than 2 cm, extraosseous distractors may be preferable to prevent the tilting of osteotomized portion along its longitudinal axis.41,45 In moderate alveolar widths, the rod of the intraosseous distractor may weaken the transport segment and breakage may occur during distraction when the soft tissue tension increases.22
With the attempt to shorten the treatment duration and to preserve the surgical site from the trauma of removing the distractor and placing the implant 8 to 16 weeks after the completion of the distraction, it was proposed the DID64: it combines the functions of a distraction device and a dental implant, requiring only 1 operation for both placement of the distractor and insertion of the implant. Only a few case reports about DID have been published,2,44,64 and there is a poverty of knowledge about their biomechanical properties, the histomorphometric features of the new regenerate bone, and the entity and distribution of osteointegration along the structure of the devices.49
An in vitro study postulated that lengthening the portion of the device anchored in the transport segment is important to bear the loading forces and to reduce the marginal bone resorption; furthermore, the authors found a ratio of 8:2 between the length of transport portion and that of the supporting basal portion of the DID as the correct ratio to support the prosthetic loading.35
In the authors’ reported case (see “Results”), there was very limited bone height to perform other reconstructive techniques. The only alternative would have been the use of 5-mm long implants. The good results with the use of these short implants with 5 to 7 mm of available bone above the mandibular canal after 4 months of follow-up34 dramatically decreased after 5 years of loading.30
The distractor used in this case allowed us to obtain the sufficient vertical dimension for standard implants placement with a mini-invasive surgical approach, reducing the detachment of buccal soft tissues. The device was well tolerated by the patient with no postoperative discomfort. The use of a DID was excluded for the low results in literature in term of implant success35 and because the anatomical situation was not appropriate for the biomechanical characteristics of these distractors.
The entity of the atrophy in this case did not allow us to osteotomize a transport segment higher than 3 mm; this dimension, smaller respect to the minimal height requested in literature with intraosseous devices or DIDs,41,44 was permitted considering the reduced dimensions of the upper screw (4 × 3.2 mm) of our distractor. It is important to highlight that the width in the buccal-lingual direction must be ≥0.5 cm, with a uniform profile edge as in our case, because this technique is not indicate in correcting a knife-edge shape residual ridge.
In consideration of the reduced dimension of the transport segment, with the risk of fracture or of necrosis, we decided to fractionate the daily distraction rate prolonging the distraction period.
The device used in this case could be easily removed with no damage to the hard and soft tissues of the treated area, which resulted adequate for the placement of a standard-length fixture.
Many points are still to be cleared in the application of the distraction technique to resolve the atrophies of the jaws. After an initial enthusiasm for this procedure, followed probably to limited experimentation and standardization, many studies underlined its drawbacks and complications.5 The fact that the complication rate dramatically decreases with the experience of the operator5 may be in line with the necessity of further investigations.
Recently, some studies pointed out the possibility to take advantage from this interesting procedure, especially in those situations such as atrophic posterior mandible, where the only alternative is the use of short implants.35–37,49,65 The results of alveolar DO depend on different variables that need to be studied to investigate the real power of this technique and the indications for its application. In particular, it must be defined which is the correct device for the different anatomical situations, the correct dimension of the transport segment, and the correct timing of the treatment. A study concludes that the clinician must choose an ideal size and type of the distractor according to defect size, shape, patient tolerance, and distance to the opposing arch.22
The authors maintain that the protocol used in this case can be appropriate to treat this particular zone, and we want to verify with a prospective study if, considering the good results obtained in this case report, this procedure could become a reliable solution in the future.
The proposed technique allowed us to rehabilitate a very atrophied posterior mandible without prosthetic compromises, avoiding grafting procedures. No complications or discomfort for the patient have been recorded.
In the opinion of the authors, this technique deserves to be investigated to verify its real value in treating this particular anatomical site.
The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
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