Accepted Manuscript The palatal approach to distraction osteogenesis of the anterior maxillary alveolus Robert E. Bell, DDS PII:
S0278-2391(15)00179-2
DOI:
10.1016/j.joms.2015.02.005
Reference:
YJOMS 56662
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 5 October 2014 Revised Date:
11 February 2015
Accepted Date: 11 February 2015
Please cite this article as: Bell RE, The palatal approach to distraction osteogenesis of the anterior maxillary alveolus, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2015.02.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
*Title Page
ACCEPTED MANUSCRIPT
Title: The palatal approach to distraction osteogenesis of the anterior maxillary alveolus Author: Robert E Bell DDS 1080 N. Cherry ave
RI PT
Tulare CA 93274 Private practice Tulare CA Phone: (559) 685-0725
SC
Fax: (559) 685-9605
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M AN U
E-mail [email protected]
ACCEPTED MANUSCRIPT
The Palatal Approach to Distraction Osteogenesis of the Anterior Maxilla Purpose: This paper describes the palatal approach to gain access for osteodistraction of the anterior maxilla in order to improve the vector of force during distraction.
RI PT
Patients and methods: This is a case report which illustrates a novel approach to anterior maxillary osteodistraction. The palatal approach allows the maxillary segment to be moved anteriorly and inferiorly. This is in contrast to the buccal approach, in which the palatal tissue creates a vector of force toward the palate. The vascular pedicle for the transport segment is the labial mucosa and musculature.
SC
Results: In this case the alveolar segment was advanced 3.6 mm anteriorly and 12.2mm inferiorly as measured by pre and post-operative CT scans. This patient with a large vertical alveolar defect and high smile line was successfully restored with dental implants. The result has been stable for 14 months.
M AN U
Conclusion: In this case, the palatal approach to the anterior maxillary osteotomy was shown to be an effective method of reconstructing a large vertical anterior defect. Introduction: Distraction osteogenesis which was first described by Codivilla and developed by Illizarov for orthopedic lengthening of long bones has been used to successfully lengthen various parts of the maxillofacial skeleton1,2. In 1973 Snyder et al used an external device to experimentally lengthen a canine mandible.3 This was followed in 1992 by McCarthy who successfully used distraction osteogenesis in a human patient with hemifacial microsomia.4
TE D
Osteodistraction has been shown to be an effective procedure to increase deficient alveolar ridge height. Chin and Toth were the first to report a case of alveolar distraction using a transport pin which transversed the alveolar segment.5 Alveolar ridge distraction has shown reasonable vertical stability and excellent implant integration rates.6,7,8
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Distraction osteogenesis of the anterior maxilla has typically been performed through an incision in the buccal vestibule. A segmental osteotomy is then performed and pediculed on the palatal mucosa. After a latency period, distraction of the alveolar segment is carried out via a mechanical device at a rate of 0.5-1mm per day. The controlled lengthening of the callus increases the bony height of the alveolus. One difficulty with osteodistraction of the anterior maxillary alveolus is that the firm palatal tissue creates a large vector of force toward the palate. This causes the segment to move posteriorly towards the palate as it moves inferiorly. This almost invariably increases the already existent anterior posterior (AP) horizontal defect. Often, additional grafting is necessary to address this AP defect. Several strategies have been used to attempt to correct this palatal vector of force including distraction through a stent or orthodontic device and the placement of two distraction devices.9, 10 These attempts to overcome the firm pull of the palatal mucosa can yield less than ideal results and there is often the need for secondary bone grafting to restore the AP deficiency. Very large defects can leave the segment in such a posterior position that it is difficult to restore even with additional grafting.
ACCEPTED MANUSCRIPT
In 2013 Bell described a palatal approach to the maxillary anterior segmental osteotomy with interpositional bone grafting.11 That study demonstrated that when using a palatal approach instead of a buccal approach the osteotomy segment could be advanced anteriorly, as well as inferiorly.
RI PT
The current case demonstrates the palatal approach used during osteodistraction of the anterior maxillary alveolus to achieve an anterior and inferior movement of the transport segment.
SC
Case Report: A 32 year old male with a high smile line presented with a very large anterior maxillary defect of traumatic origin. A previous attempt to graft the area with guided bone regeneration had failed. The defect measured 11.2mm vertically and 19.8mm mesial distally. (fig. 8) When the patient smiled the entire defect was visible.(fig. 1) Options were discussed with the patient and the decision was made to use osteodistraction via a palatal approach.
M AN U
Under intravenous sedation an incision was made along the crest of the ridge at the defect site and was carried posteriorly as an envelope flap around the palatal aspect of teeth 5 thru 11. Vertical releasing incisions were created at the palatal aspects of 4 and 12 to improve access. (fig. 2,3)
TE D
A sagittal saw was used to create vertical osteotomies in the alveolus adjacent to teeth 6 and 10. Care was taken to assure the osteotomies were slightly convergent at the base to allow future movement of the segment.(fig.4) The horizontal osteotomy was made using an oscillating saw.(fig 5) An small osteotome was used to complete the osteotomy. In this case, the LEAD intraosseous distraction system (Leibinger) was used for the alveolar distraction. As per protocol for this device, a drill was used to create a trans-alveolar osteotomy through the osteotomy segment for the transport screw. A base plate and transport plate were bent and fixated to the basal bone and transport segment at the horizontal osteotomy site and the transport screw was inserted into these plates.(fig. 6) The wound was then closed.(fig. 7) An essex type of temporary was used for tooth replacement during distraction.
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After a latency phase of one week, distraction began using the transport screw. Distraction was carried out at a rate of 0.5 mm per day. The distraction phase lasted 23 days. The transport screw was maintained in place for an additional 30 days to allow the grafts to heal and was then removed. The total amount of movement was 12.2 mm vertically and 3.6 mm anteriorly. (fig. 8,9,10,11) Six weeks after the end of distraction, and two weeks after removal of the transport screw, implants were placed. A Straumman bone level 4.1 mm x1 4 mm implant was used for tooth 8 and 3.3 mm x 14 mm Roxolid implant was used for tooth 10 in preparation for an implant born fixed bridge. During the implant surgery, approximately 2 mm of alveloplasty was performed at the implant sites to reduce the ridge height, create a scalloped ridge, and increase the width of the bone. (fig. 12) The transport plate was also removed as part of the implant surgery. The base plate was left in place. After three months both implants had integrated. The gingival tissue was irregular. This was addressed by mechanical and laser resurfacing and a custom implant-born fixed temporary bridge. (fig.13) After six weeks of healing the patient returned to his dentist for final impressions and fabrication of the final prosthesis. (fig.14) The final prosthesis demonstrated acceptable esthetics without the need for gingival colored porcelain.
ACCEPTED MANUSCRIPT
Discussion: This case demonstrated that the palatal approach to osteodistraction creates an anterior and inferior vector of force. The buccal vascular pedical allowed the segment to move into the proper anterior posterior position without any exterior guidance. This difficult esthetic case was completed without the need for a secondary grating procedure.
RI PT
One concern with this approach was that after closure, the palatal tissue would still deflect the segment toward the palate during distraction. This did not occur. It appeared that the area of the incision formed new gingiva as the segment advanced.
SC
As described previously for the sandwich osteotomy, with proper instrumentation, completing the osteotomy from the palatal approach was not difficult. The micro-osscillating saw affords excellent access for the horizontal cut. An esthetic result was obtained in this case and over the short follow up period, the amount of vertical and horizontal gain has been clinically and radiographicaly stable for 12 months post implant placement.
M AN U
Conclusion: The palatal approach to maxillary alveolar osteodistration is a viable option for increasing alveolar ridge height. It overcomes the main limitation of the buccal approach, the palatal vector of force, thus increasing the indications for this procedure. The palatal approach allowed this patient’s deficient maxillary alveolar ridge to move inferiorly and anteriorly into the correct anatomic position for anesthetic dental restoration. The result has been very stable over the short period of follow-up.
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1. Ilizarou GA: The tension-stress effect on the genesis and growth of tissues. Part I: The influence of stability of fixation and soft tissue preservation. Clin Orthop 238:249, 1989 2. Ilizarou GA: The tension-stress effect on the genesis and growth of tissues. Part II: The influence of rate and frequency of distraction. Clin Orthop 239:263, 1989 3. Snyder, CC, et al: Mandibular lengthening by gradual distraction: Preliminary report. Plastic and Recon Surg 51:506, May 1973 4. McCarthy JG, et al: Lengthening the human mandible by gradual distraction. Plastic and Recon Surg 89:102, Jan 1992 5. Chin M, Toth BA: Distraction osteogenesis in maxillofacial surgery using internal devices: Review of five cases. J Oral Maxillofac Surg 54:45, 1996 6. Saulacic N, et al: Relapse in alveolar distraction osteogenesis an indication for overcorrection. J Oral Maxillofac Surg 63:976, July 2005 7. Saulacic W, et al: Alveolar distraction osteogenesis: A systematic review. International J Oral and Maxillofac Surg 37:1, Jan 2008 8. Elo JA, Herford AS, Boyne PJ: Implant success in distracted bone versus autogenous bone— grafted sites. J Oral Implant 35:181, Aug 2009 9. Cano J, et al: Osteogenic alveolar distraction, a review of the literature. Oral Surg, Oral Med, Oral Path, Oral Rad, and endodontology 101:11, Jan 2006 10. Robiony M, et al: the “FAD” (floating alveolar device): A bi-directional distraction system for distraction osteogenesis of the alveolar process. J Oral Maxillofac Surg 62:136, Sept 2004
ACCEPTED MANUSCRIPT
11. Bell, RE: Palatal approach to the anterior maxillary sandwich osteotomy. J Oral Maxillofac Surg 71:1005, June 2013
Figure 2 Incision Figure 3 Flap elevation Figure 4 Vertical osteotomy with a sagittal saw Figure 5 Horizontal osteotomy with an oscillating saw
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Figure 1 Preoperative lip mobility
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Figure Legend:
Figure 7 Wound closure Figure 8 Pre-operative radiograph
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Figure 6 Distraction hardware A) screw B)Baseplate C)Transport plate D)Osteotomy Distraction
Figure 9 Sagittal radiograph distracted fragment Figure 10 Post-distraction CT scan
Figure 12 Implant surgery
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Figure 11 Post-distraction ridge
Figure 13 Postop soft tissue sculpting
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Figure 14 Final restoration
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S0278-2391(15)00179-2
DOI:
10.1016/j.joms.2015.02.005
Reference:
YJOMS 56662
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 5 October 2014 Revised Date:
11 February 2015
Accepted Date: 11 February 2015
Please cite this article as: Bell RE, The palatal approach to distraction osteogenesis of the anterior maxillary alveolus, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2015.02.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
*Title Page
ACCEPTED MANUSCRIPT
Title: The palatal approach to distraction osteogenesis of the anterior maxillary alveolus Author: Robert E Bell DDS 1080 N. Cherry ave
RI PT
Tulare CA 93274 Private practice Tulare CA Phone: (559) 685-0725
SC
Fax: (559) 685-9605
AC C
EP
TE D
M AN U
E-mail [email protected]
ACCEPTED MANUSCRIPT
The Palatal Approach to Distraction Osteogenesis of the Anterior Maxilla Purpose: This paper describes the palatal approach to gain access for osteodistraction of the anterior maxilla in order to improve the vector of force during distraction.
RI PT
Patients and methods: This is a case report which illustrates a novel approach to anterior maxillary osteodistraction. The palatal approach allows the maxillary segment to be moved anteriorly and inferiorly. This is in contrast to the buccal approach, in which the palatal tissue creates a vector of force toward the palate. The vascular pedicle for the transport segment is the labial mucosa and musculature.
SC
Results: In this case the alveolar segment was advanced 3.6 mm anteriorly and 12.2mm inferiorly as measured by pre and post-operative CT scans. This patient with a large vertical alveolar defect and high smile line was successfully restored with dental implants. The result has been stable for 14 months.
M AN U
Conclusion: In this case, the palatal approach to the anterior maxillary osteotomy was shown to be an effective method of reconstructing a large vertical anterior defect. Introduction: Distraction osteogenesis which was first described by Codivilla and developed by Illizarov for orthopedic lengthening of long bones has been used to successfully lengthen various parts of the maxillofacial skeleton1,2. In 1973 Snyder et al used an external device to experimentally lengthen a canine mandible.3 This was followed in 1992 by McCarthy who successfully used distraction osteogenesis in a human patient with hemifacial microsomia.4
TE D
Osteodistraction has been shown to be an effective procedure to increase deficient alveolar ridge height. Chin and Toth were the first to report a case of alveolar distraction using a transport pin which transversed the alveolar segment.5 Alveolar ridge distraction has shown reasonable vertical stability and excellent implant integration rates.6,7,8
AC C
EP
Distraction osteogenesis of the anterior maxilla has typically been performed through an incision in the buccal vestibule. A segmental osteotomy is then performed and pediculed on the palatal mucosa. After a latency period, distraction of the alveolar segment is carried out via a mechanical device at a rate of 0.5-1mm per day. The controlled lengthening of the callus increases the bony height of the alveolus. One difficulty with osteodistraction of the anterior maxillary alveolus is that the firm palatal tissue creates a large vector of force toward the palate. This causes the segment to move posteriorly towards the palate as it moves inferiorly. This almost invariably increases the already existent anterior posterior (AP) horizontal defect. Often, additional grafting is necessary to address this AP defect. Several strategies have been used to attempt to correct this palatal vector of force including distraction through a stent or orthodontic device and the placement of two distraction devices.9, 10 These attempts to overcome the firm pull of the palatal mucosa can yield less than ideal results and there is often the need for secondary bone grafting to restore the AP deficiency. Very large defects can leave the segment in such a posterior position that it is difficult to restore even with additional grafting.
ACCEPTED MANUSCRIPT
In 2013 Bell described a palatal approach to the maxillary anterior segmental osteotomy with interpositional bone grafting.11 That study demonstrated that when using a palatal approach instead of a buccal approach the osteotomy segment could be advanced anteriorly, as well as inferiorly.
RI PT
The current case demonstrates the palatal approach used during osteodistraction of the anterior maxillary alveolus to achieve an anterior and inferior movement of the transport segment.
SC
Case Report: A 32 year old male with a high smile line presented with a very large anterior maxillary defect of traumatic origin. A previous attempt to graft the area with guided bone regeneration had failed. The defect measured 11.2mm vertically and 19.8mm mesial distally. (fig. 8) When the patient smiled the entire defect was visible.(fig. 1) Options were discussed with the patient and the decision was made to use osteodistraction via a palatal approach.
M AN U
Under intravenous sedation an incision was made along the crest of the ridge at the defect site and was carried posteriorly as an envelope flap around the palatal aspect of teeth 5 thru 11. Vertical releasing incisions were created at the palatal aspects of 4 and 12 to improve access. (fig. 2,3)
TE D
A sagittal saw was used to create vertical osteotomies in the alveolus adjacent to teeth 6 and 10. Care was taken to assure the osteotomies were slightly convergent at the base to allow future movement of the segment.(fig.4) The horizontal osteotomy was made using an oscillating saw.(fig 5) An small osteotome was used to complete the osteotomy. In this case, the LEAD intraosseous distraction system (Leibinger) was used for the alveolar distraction. As per protocol for this device, a drill was used to create a trans-alveolar osteotomy through the osteotomy segment for the transport screw. A base plate and transport plate were bent and fixated to the basal bone and transport segment at the horizontal osteotomy site and the transport screw was inserted into these plates.(fig. 6) The wound was then closed.(fig. 7) An essex type of temporary was used for tooth replacement during distraction.
AC C
EP
After a latency phase of one week, distraction began using the transport screw. Distraction was carried out at a rate of 0.5 mm per day. The distraction phase lasted 23 days. The transport screw was maintained in place for an additional 30 days to allow the grafts to heal and was then removed. The total amount of movement was 12.2 mm vertically and 3.6 mm anteriorly. (fig. 8,9,10,11) Six weeks after the end of distraction, and two weeks after removal of the transport screw, implants were placed. A Straumman bone level 4.1 mm x1 4 mm implant was used for tooth 8 and 3.3 mm x 14 mm Roxolid implant was used for tooth 10 in preparation for an implant born fixed bridge. During the implant surgery, approximately 2 mm of alveloplasty was performed at the implant sites to reduce the ridge height, create a scalloped ridge, and increase the width of the bone. (fig. 12) The transport plate was also removed as part of the implant surgery. The base plate was left in place. After three months both implants had integrated. The gingival tissue was irregular. This was addressed by mechanical and laser resurfacing and a custom implant-born fixed temporary bridge. (fig.13) After six weeks of healing the patient returned to his dentist for final impressions and fabrication of the final prosthesis. (fig.14) The final prosthesis demonstrated acceptable esthetics without the need for gingival colored porcelain.
ACCEPTED MANUSCRIPT
Discussion: This case demonstrated that the palatal approach to osteodistraction creates an anterior and inferior vector of force. The buccal vascular pedical allowed the segment to move into the proper anterior posterior position without any exterior guidance. This difficult esthetic case was completed without the need for a secondary grating procedure.
RI PT
One concern with this approach was that after closure, the palatal tissue would still deflect the segment toward the palate during distraction. This did not occur. It appeared that the area of the incision formed new gingiva as the segment advanced.
SC
As described previously for the sandwich osteotomy, with proper instrumentation, completing the osteotomy from the palatal approach was not difficult. The micro-osscillating saw affords excellent access for the horizontal cut. An esthetic result was obtained in this case and over the short follow up period, the amount of vertical and horizontal gain has been clinically and radiographicaly stable for 12 months post implant placement.
M AN U
Conclusion: The palatal approach to maxillary alveolar osteodistration is a viable option for increasing alveolar ridge height. It overcomes the main limitation of the buccal approach, the palatal vector of force, thus increasing the indications for this procedure. The palatal approach allowed this patient’s deficient maxillary alveolar ridge to move inferiorly and anteriorly into the correct anatomic position for anesthetic dental restoration. The result has been very stable over the short period of follow-up.
AC C
EP
TE D
1. Ilizarou GA: The tension-stress effect on the genesis and growth of tissues. Part I: The influence of stability of fixation and soft tissue preservation. Clin Orthop 238:249, 1989 2. Ilizarou GA: The tension-stress effect on the genesis and growth of tissues. Part II: The influence of rate and frequency of distraction. Clin Orthop 239:263, 1989 3. Snyder, CC, et al: Mandibular lengthening by gradual distraction: Preliminary report. Plastic and Recon Surg 51:506, May 1973 4. McCarthy JG, et al: Lengthening the human mandible by gradual distraction. Plastic and Recon Surg 89:102, Jan 1992 5. Chin M, Toth BA: Distraction osteogenesis in maxillofacial surgery using internal devices: Review of five cases. J Oral Maxillofac Surg 54:45, 1996 6. Saulacic N, et al: Relapse in alveolar distraction osteogenesis an indication for overcorrection. J Oral Maxillofac Surg 63:976, July 2005 7. Saulacic W, et al: Alveolar distraction osteogenesis: A systematic review. International J Oral and Maxillofac Surg 37:1, Jan 2008 8. Elo JA, Herford AS, Boyne PJ: Implant success in distracted bone versus autogenous bone— grafted sites. J Oral Implant 35:181, Aug 2009 9. Cano J, et al: Osteogenic alveolar distraction, a review of the literature. Oral Surg, Oral Med, Oral Path, Oral Rad, and endodontology 101:11, Jan 2006 10. Robiony M, et al: the “FAD” (floating alveolar device): A bi-directional distraction system for distraction osteogenesis of the alveolar process. J Oral Maxillofac Surg 62:136, Sept 2004
ACCEPTED MANUSCRIPT
11. Bell, RE: Palatal approach to the anterior maxillary sandwich osteotomy. J Oral Maxillofac Surg 71:1005, June 2013
Figure 2 Incision Figure 3 Flap elevation Figure 4 Vertical osteotomy with a sagittal saw Figure 5 Horizontal osteotomy with an oscillating saw
SC
Figure 1 Preoperative lip mobility
RI PT
Figure Legend:
Figure 7 Wound closure Figure 8 Pre-operative radiograph
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Figure 6 Distraction hardware A) screw B)Baseplate C)Transport plate D)Osteotomy Distraction
Figure 9 Sagittal radiograph distracted fragment Figure 10 Post-distraction CT scan
Figure 12 Implant surgery
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Figure 11 Post-distraction ridge
Figure 13 Postop soft tissue sculpting
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Figure 14 Final restoration
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