Closure of a large alveolar cleft by bony transport of a posterior segment using orthodontic archwires attached to bone: report of a case

Indications and surgical technique for distraction osteogenesis of the alveolar bone for augmentation prior to insertion of dental implants

When bone is limited, short, ultra-short, or narrow implants help to restore oral rehabilitation with an acceptable long-term outcome. This becomes more difficult with severe vertical bone loss. Guided bone regeneration, onlay block transplantation, or sandwich osteotomy have been established to build up these defects. The alternative to the alveolar distraction osteogenesis (ADO) has only been established in some centers, with a standardized protocol. On the one hand, ADO is a biological procedure that allows almost a "restitutio ad integrum" when building up hard and soft tissue. On the other hand, there are clear indications, limitations, and complications of the procedure in the literature. In addition to the literature, concept of Tissue Regeneration by Alveolar Callusdistraction Cologne (TRACC), which has been practiced successfully for over two decades, will be presented for different indications.

Orthodontic Pre Grafting Closure of Large Alveolar Bony and Soft Tissue Gaps: A Novel Nonsurgical Protraction of the Lesser Segments in Growing Patients With Cleft Lip and Palate

BACKGROUND

Closure of wide alveolar clefts with large soft tissue gaps and reconstruction of the dentoalveolar defect are challenging for the surgeon. Some authors successfully used interdental segmental distraction, which requires an additional surgical procedure.

OBJECTIVE

This study evaluates the effectiveness of tooth borne devices utilized to orthopedically advance the lesser segments, with a complete approximation of the soft tissue of the alveolar stumps, allowing traditional simultaneous soft tissue closure and bone grafting, and avoiding the need for supplementary surgery.

METHODS

Eight growing patients, 2 with unilateral complete cleft lip and palate (UCLP) and 6 with bilateral complete cleft lip and palate (BCLP), with large soft tissue and bony alveolar defects prior to bone grafting were prospectively selected. A banded rapid palatal expander (RPE) in BCLP and a modified RPE in UCLP combined with protraction face mask in younger patients or a modified Alt-Ramec in patients older than 12 years were applied. Radiographic and photographic records were available at T0, at the end of protraction (T1) and at least 1 year after bone grafting (T2).

RESULTS

Patients with large gaps showed a significant reduction in the bony cleft area and approximation of the soft tissues at T1. All patients received bone grafting with good healing and ossification at T2.

CONCLUSION

In growing patients with UCLP and BCLP with large gaps, presurgical orthodontic protraction seems to be an efficient method to reduce the cleft defect, minimizing the risk of post grafting fistulas, reducing the need for supplementary surgical procedures.

Horizontal alveolar transport distraction osteogenesis followed by implant placement

Alveolar transport distraction osteogenesis (ATDO) is an alternative treatment method to vertical alveolar distraction osteogenesis in cases of large bony defects, especially when the bone is limited in size. ATDO was performed in 10 patients with 12 defects. The mean age of the patients was 39.1years. The average bone length gain was 18.2mm. Implants were inserted following a 3-month consolidation period. Three patients needed additional bone grafting for horizontal widening. Final prosthetic rehabilitation was performed at least 3 months following implant insertion. The mean follow-up period was 63 months and the survival rate of the 25 implants placed was 92%. All failures (n=2) occurred during the early healing period. Although the results are not totally predictable, it can be concluded that ATDO can be effective in the reconstruction of the alveolar crest prior to implant placement.

Attitude of the Canine in Secondary Bone-Grafted and Nongrafted Patients with Cleft Lip and Palate

Objective

To investigate the eruption pattern of the cleft-side canine regarding its pre-eruption position relative to the cleft in bone-grafted (BG) and nongrafted (NonBG) patients with cleft lip and palate.

Methods

Fifty-three patients with cleft lip and palate (21 BG, 32 NonBG) were examined by panoramic radiography and posteroanterior cephalography taken before and after canine eruption. Subjects were categorized into BG, NonBG, and control groups. Canines at the pre-eruption stage were categorized as close to (group 1) or distant from (group 2) the cleft area. The canine angle and its change between the two stages were evaluated.

Results

No significant differences were noted between the initial canine angle of the BG and NonBG groups. Although canines in the BG group erupted without a significant change in angle, the canine angle increased significantly (p < .0001) in the NonBG and control groups. In group 1, a greater change in canine angle was noted in the NonBG (p < .05) and control (p < .01) groups than in the BG group. In group 2, no significant difference was noted among the three groups.

Conclusions

In BG patients, a canine located near the cleft appears to erupt at the same angle as it had before grafting. However, in NonBG patients, it erupts more vertically, guided by cortical bone. For canines distant from the cleft area, there is no significant difference in the change in angulation between NonBG and BG patients.

Bilateral Alveolar Distraction for Large Alveolar Defects: Case Report

Distraction osteogenesis has become a very popular technique, as the ability to reconstruct combined deficiencies in bone and soft tissue makes this process unique and invaluable to all types of reconstructive surgeons. We document a case in which an intraoral tooth-borne distractor was designed and segmental alveolar distraction was performed in a large alveolar defect in a patient with bilateral cleft lip and palate. Cosmetic dentistry was performed to attain a pleasing result. This article aims at highlighting the use of distraction in large defects in which bone grafting only is not a suitable procedure.

Interdental osteotomies induce regional acceleratory phenomenon and accelerate orthodontic tooth movement

PURPOSE

Although it has been revealed clinically that double-jaw orthognathic surgery induces a systemic increase in the baseline bone turnover and subsequently accelerates postoperative orthodontic tooth alignment, it is not clear whether less extensive osteotomy, such as interdental osteotomy, would be intensive enough to accelerate postoperative orthodontic tooth alignment.

MATERIALS AND METHODS

Twelve adult male beagle dogs were randomly assigned to 2 groups. The sham control group (n = 6) received orthodontic tooth alignment of the maxillary incisors, and the experimental group (n = 6) received orthodontic tooth alignment of the maxillary incisors and interdental osteotomies between the maxillary third incisor and canine on both sides concurrent with the beginning of orthodontic tooth alignment. The duration of orthodontic tooth alignment was 3 months in both groups. Cone-beam computed tomography scans of the maxilla, dental casts, blood samples, and gingival crevicular fluid (GCF) of the maxillary incisors were taken immediately before orthodontic tooth alignment (T0) and 1 week (T1) and 1 (T2), 2 (T3), and 3 (T4) months after beginning orthodontic tooth alignment. They were analyzed for changes in the interdental alveolar bone gray scale (osteoporosity) of the maxillary incisors, irregularity index (rate of orthodontic tooth alignment), and bone-specific alkaline phosphatase (bALP, a biomarker of osteoblastic activity) and C-terminal telopeptide of type I collagen (ICTP, a biomarker for osteoclastic activity) in the serum and GCF samples from T0 to T4. The data were analyzed statistically for inter- and intragroup differences.

RESULTS

The rate of orthodontic tooth alignment for the experimental group was significantly greater and twofold that of the sham control group at T1, T2, T3, and T4. The serum-bALP, serum-ICTP, GCF-bALP, GCF-ICTP, and osteoporosity remained similar from T0 to T4 in the sham control group. In contrast, GCF-bALP increased two- to threefold from T1 to T4, and GCF-ICTP increased fivefold at T1 and then gradually decreased from T2 to T4. The interdental osteoporosity significantly increased from T1 to T4, but the serum-bALP and serum-ICTP levels remained similar, without significant changes in the experimental group.

CONCLUSIONS

Interdental osteotomy induced a regional, but not a systemic, acceleratory phenomenon and was intensive enough to accelerate postoperative orthodontic tooth alignment twofold. The intensity of the increase in the bone turnover rate and osteoporosity might depend on the extent of the osteotomy.

Wide alveolar cleft and midface distraction: Report of a case

BACKGROUND

Cleft lip and palate patients often present wide alveolar cleft and midface hypoplasia. Closure of such wide alveolar clefts may be difficult using bone graft. Traditional orthognathic surgery for midface advancement shows relapse. Distraction osteogenesis (DO) as a modality for midface advancement has shown good results with external distractors. Use of internal distractor (ID) further improves patient compliance, causes minimal discomfort and offers the advantage of limiting relapse. The purpose of this study was to evaluate the versatility of intraoral distracters in midface advancement in cases with alveolar cleft.

METHOD

A 16 years old young girl with midface deficiency and alveolar cleft visited our outpatient clinic for aesthetic improvement and midface distraction was planned. After Le Fort I osteotomy, internal distractor was fixed. A latency period of 5 days was allowed and then distraction was started at the rate of 1 mm per day in two installments. Evaluation was done for closure of cleft, ease of the procedure, stability, and complications. Lateral cephalograms were evaluated at three stages: predistraction; post-distraction; and 1 year post-distraction.

RESULTS

Complete closure of alveolar cleft was observed with 17 mm midface advancement and bone formation at the pterygomaxillary region. Maxillary position improved in relation to the cranial base. The results were stable even at 1 year follow-up.

CONCLUSION

Distraction osteogenesis using intraoral distractors was successful in alveolar cleft closure, as well as midface advancement in terms of stability of results and patient compliance with minimal complications.

Closure of the alveolar cleft by bone segment transport using an intraoral tooth-borne custom-made distraction device

PURPOSE

The fact that bone transportation generates not only bone but also surrounding soft tissues makes it an ideal technique for tissue regeneration. This study evaluates bone segment transport using an intraoral tooth-borne distraction device for alveolar cleft closure.

MATERIALS AND METHODS

Patients with an alveolar cleft were enrolled in the study. They were treated at the Al-Azhar University Hospital, Cairo, Egypt, between 2004 and 2007. Anterior transportation of the posterior dentoalveolar segment was performed by use of an intraoral tooth-borne custom-made distractor. Clinical evaluations included the following: preoperative and postoperative intraoral photographs, vitality testing of the teeth in the transport segment, cast analysis, and measurement of tooth mobility. Radiographic evaluations included occlusal films, orthopantomography, and computed tomography and 3D computed tomography for volumetric and densitometric evaluations of the distracted bone.

RESULTS

After distraction was completed, the transported segments were positioned 1 to 4 mm superior to the occlusal plane. The radiographic evaluation showed residual triangular bone deficits that were closed through gingivoperiosteoplasty or bone grafting. Once the transported segments came in contact with the alveolar bone of the normal side, the intervening fibrous tissue at the docking site was removed, and docking-site surgery was then performed. The results obtained from both clinical examinations and radiographic imaging showed complete closure of the alveolar clefts.

CONCLUSIONS

Maxillary alveolar bone transport offers an alternative technique in the latest treatment of the alveolar cleft.

Treatment of alveolar cleft with distraction osteogenesis using anchorage with a tooth-microimplant joint in a dog model

Our aim was to investigate the efficacy of correction of an alveolar cleft with distraction osteogenesis using anchorage with a tooth-microimplant joint in a canine model, which was established in 12 adult mongrel dogs that were subsequently randomised into two groups (n=6 in each). The first group comprised dogs that had osteogenesis using anchorage with a tooth (tooth group), while in the second, anchorage with tooth-microimplant joint (microimplant group) was used. All animals were killed one month after completion of distraction. Samples were collected for gross observation and histological examination. There was a significant difference in the degree of movement of the anchorage teeth in the transport discs between the 2 groups (p<0.01). There was less prominent inclination and shift of the natural teeth in the transport disc and less bony resorption around the root in the microimplant group than in the tooth group. These changes were less remarkable in the microimplant group. Treatment of alveolar cleft by distraction osteogenesis using anchorage with a tooth-microimplant joint is practical, and yields better results.

Bilateral vertical segmental distraction in a patient with bilateral cleft of lip, alveolus, and palate

In cases of bilateral clefts of lip and palate there is often a vertical and transversal deficit of the cleft segments. Ideally these problems can be solved orthodontically. In severe cases there is a need of surgical support. Distraction osteogenesis allows the correction of transversal, horizontal, and vertical deficits. A case of a 13-year-old girl with a bilateral cleft of lip and palate is presented. The patient had a severe deficit of the distal cleft segments concerning the vertical and transversal dimension. Osteotomy of the segments was performed and a vertical distraction followed by a transpalatal distraction procedure was used to correct the discrepancies.

Amount of bone lengthening affects blood flow recovery and bone mineralization after distraction osteogenesis in a canine cleft palate model

OBJECTIVES

Distraction osteogenesis has been applied to the craniofacial region. To reduce the cleft width of patients with cleft lip and palate, alveolar bones are distracted toward the cleft. However, no reports have described limitations to the amount of lengthening that can be achieved by distraction osteogenesis in this area. Therefore, we investigated the healing process following different extents of distraction osteogenesis using a canine cleft palate model.

METHODS

A 10-mm bone defect was made in the palates. A bony segment including the canine was prepared and translocated into the defect area at a rate of 1 mm/d for 6 or 10 days, resulting in two groups (6- and 10-mm groups). Canine pulpal blood flow was monitored for 100 days with Doppler flowmetry. Then, the animals were sacrificed and the regenerated bone area was evaluated radiologically and histologically. Statistical significance was confirmed with the Mann-Whitney rank test.

RESULTS

Pulpal blood flow in the 6-mm group recovered to original levels earlier than in the 10-mm group. Cortical bone density in the regenerated bone, measured by peripheral quantitative computed tomography, was significantly greater in the 6-mm group than in the 10-mm group. The amount of regenerated bone in histologic sections was also significantly greater in the 6-mm group.

CONCLUSION

We clearly showed that healing progress depends on the extent of distraction osteogenesis, highlighting the importance of limited distraction osteogenesis in the alveolar area.

Tisssue responses in corticotomy- and osteotomy-assisted tooth movements in rats: histology and immunostaining

INTRODUCTION

The purpose of this histologic study was to examine underlying cellular responses to corticotomy- and osteotomy-assisted tooth movements.

METHODS

Thirty-six rats were divided into 5 groups: corticotomy-assisted tooth movement (CO + TM), sham corticotomy without tooth movement (CO alone), osteotomy-assisted tooth movement (OS + TM), sham osteotomy without tooth movement (OS alone), and unassisted tooth movement (TM alone). Standard orthodontic springs were activated to produce mesial tooth movement. The rats were killed at 3, 21, and 60 days after activation for osteoclast and blood vessel counts, and immunostaining with proliferating cell nuclear antigen (PCNA), transforming growth factor beta 1 (TGF beta 1), vascular endothelial growth factor (VEGF), and osteocalcin were performed.

RESULTS

The CO + TM group had significantly more osteoclasts at 3 days (P <0.005) compared with the OS + TM group. The alveolar bone surrounding the dental roots was replaced with multicellular tissue at 21 days in the CO + TM group but was intact in the OS + TM group with the exception of a distal distraction site. At day 21, immunostaining with PCNA, TGF beta 1, VEGF, and osteocalcin occurred at the mesial border of bone in the CO + TM group, whereas a diffuse pattern was observed in the distal distraction sites at 21 and 60 days in the OS + TM group.

CONCLUSIONS

Corticotomy-assisted tooth movement produced transient bone resorption around the dental roots under tension; this was replaced by fibrous tissue after 21 days and by bone after 60 days. Osteotomy-assisted tooth movement resembled distraction osteogenesis and did not pass through a stage of regional bone resorption.

Corticotomy-/osteotomy-assisted tooth movement microCTs differ

Corticotomy-assisted and osteotomy-assisted tooth movement involves surgical incisions through the alveolar bone. To ascertain whether teeth move by distraction osteogenesis or by regional accelerated phenomenon (RAP), we randomly assigned 30 Sprague-Dawley rats to one of 5 experimental groups: corticotomy alone, corticotomy-assisted tooth movement, osteotomy alone, osteotomy-assisted tooth movement, or tooth movement alone. Each animal was imaged by microtomography immediately after surgery, after 21 days, and after 2 months. After 21 days, regional accelerated phenomenon was observed in the alveolar bone of the corticotomy-treated animals and distraction osteogenesis in the osteotomy-assisted tooth movement animals. Pixel count data were analyzed by nested ANOVA for 5 experimental groups, split-mouth controls, 3 levels along the root, and 5 sites per level. The most demineralized sites after 21 days differed for each of the experimental groups. Our study indicates that osteotomies and corticotomies induce different alveolar bone reactions, which can be exploited for tooth movement.

Maxillary Segmental Distraction in a Patient with Bilateral Cleft Lip and Alveolus with Subsequent Tooth Transplantation: A Preliminary Case Report

Segmental distraction osteogenesis in the maxillary alveolar process makes it possible to close alveolar clefts in patients with cleft lip and alveolus successfully. Dental spaces occurring in the lateral segment can subsequently be fully closed by transplanting teeth into this area. This new method of treatment is advantageous for patients with broad clefts and multiple missing teeth in the maxilla.

Alveolar distraction osteogenesis: a systematic review

This literature review was performed to analyse the outcomes of clinical studies of alveolar distraction osteogenesis (DO) listed by PUBMED between January 1996 and December 2006. A PUBMED search identified 128 articles on alveolar DO. Twenty articles covering 209 cases were analysed, considering location, device and procedural parameters, rate of augmentation, aspect of final implant placement and follow up. The mean latency period was 7.26+/-2.31 days, distraction rate 0.71+/-0.27 mm/day, rate of augmentation 6.88+/-2.52 mm and consolidation period 12.22+/-5.58 weeks. A total of 469 implants were placed and followed post loading for an average of 14.19+/-11.03 months, with a survival rate of 97%. Of the different procedural parameters, only the difference between mean consolidation period for failed (8.10+/-2.51 weeks) and successful (12.43+/-5.62 weeks) implants was statistically significant (P=0.01). Use of DO may be advantageous in terms of the success rate of implants placed in augmented sites, but there is still a lack of sufficient data based on long-term follow up. Future experimental studies should evaluate the application of different methods with a view to shortening the overall treatment period and improving the performance of implants placed in distracted alveolar ridges.

Cleft Lip and Palate

Patients who have cleft lip or palate face significant lifelong communicative and aesthetic challenges and difficulties with deglutition. Management of patients who have orofacial clefting requires an understanding of the anatomy and pathophysiology associated with clefting and the developmental difficulties encountered by these patients. This article describes current surgical concepts and principles of cleft care. Advances in the embryology and genetics of orofacial clefting are also discussed. It is expected that the care of patients who have clefts will continue to evolve because of advances in the fields of tissue engineering, genetics, and fetal surgery.

The Use of Internal Maxillary Distraction for Maxillary Hypoplasia: A Preliminary Report

PURPOSE

Distraction osteogenesis is a useful alternative to advance the maxilla in complicated cases of maxillary hypoplasia. The purpose of this article is to review the workup, experience, and preliminary results with the use of internal distraction osteogenesis for maxillary hypoplasia at one teaching institution.

PATIENTS AND MATERIALS

Over a 5-year period, more than 300 patients with craniofacial and dentofacial defects have undergone oral and maxillofacial surgery at our center to correct their skeletal discrepancies. Of these, 10 have had maxillary distraction osteogenesis done with internal distractors. Follow-up of 6 months or more was available for 8 patients. Stereolithographic models were used to bend distractors prior to surgery in 6 patients.

RESULTS

Latency prior to the start of distraction was 3 to 7 days and varied with the age of the patient. Distraction occurred at approximately 1 mm per day with an average distraction length of 8.5 mm (range, 6-10 mm). Excellent occlusal results were obtained in 5 patients. Major complications including nonunion and failure to achieve acceptable occlusal results were observed in 3 patients. Minor complications including pain and loosening of the distracter devices were observed in 2 patients, but did not appear to affect the esthetic and functional results.

CONCLUSIONS

Distraction osteogenesis is a useful alternative to traditional orthognathic surgery to treat maxillary hypoplasia. Internal distractions are attractive to patients, but are more difficult to place and can cause discomfort to patients when trying to achieve an ideal primary vector of distraction. Stereolithographic models can help with placement of the device. Changes in design of distractors may help with patient discomfort.

Vector Control in Transportation Osteogenesis

PURPOSE

To evaluate the ability to control vectors in the technique of transportation osteogenesis using 4 principles.

PATIENTS AND METHODS

Sixteen defects measuring approximately 30-180 mm were retrospectively evaluated. Vector control was attempted using a single or combination of the following principles: multiple linear vectors, exaggerated linear distraction ("sausage effect"), braced guided distraction, and reorientation osteotomies. Observations were made regarding the ability to create the desired vectors. Angular deviation from desired vectors was determined and recorded numerically by evaluating either submental vertex or occlusal radiographs, stereolithographic models, or digital radiographs. Radiographic evaluation of symmetry alone was not used to determine the desired vector because a more laterally displaced segment was desirable to maintain favorable facial balance when soft tissue deficiency was pronounced. A subjective evaluation scale was developed to supplement the numerical values.

RESULTS

Vector control primarily required the use of 2 or more principles. The most common combination was that of exaggerated linear distraction and reorientation osteotomy.

CONCLUSION

The use of multiple linear vectors, exaggerated linear distraction ("sausage effect"), reorientation osteotomies, and braced guided distraction greatly assisted the operator in achieving the goal of symmetrical reconstruction. Transportation osteogenesis may be considered an effective tool in the box to reconstruct patients. In cases in which vector control is achieved, the advantages of diminishing the volume of bone graft required or achieving final bony reconstruction can outweigh the disadvantages of the technique.

A multidisciplinary approach to restoring an acquired palatal defect using distraction osteogenesis: A clinical report

Prosthetic and surgical procedures can be applied to rehabilitate acquired palatal defects. Distraction osteogenesis may be used to narrow the defect to facilitate bone and soft tissue closure. This clinical report describes a multidisciplinary approach to the closure of a palatal defect with distraction osteogenesis, comprehensive orthodontic treatment, surgical soft tissue flap reconstruction of the residual soft tissue defect, implant placement in the newly created edentulous ridge, and restoration with an implant-supported prosthesis.

Management of alveolar clefts

Treatment philosophies in the management of alveolar clefts have changed greatly over the years. Currently. the most widely accepted protocol is for repair using autologous cancellous bone from the iliac crest during the stage of mixed dentition. Preliminary data suggest that the appropriate age for surgical repair during the secondary phase can be decreased without evidence of limitation of facial growth. Further long-term studies are necessary to support this protocol, however. With a multidisciplinary approach between the various medical and dental specialties, it is now commonplace to achieve normal dentofacial aesthetics and function. The continued advances in medical and dental technology have further contributed to the excellent outcomes that are now achieved.

Orthodontic treatment for patients with clefts

Orthodontic strategies continue to evolve as new methods and treatment concepts more directly address the specific problems of patients who have clefts. By continual review of treatment outcomes and comparing outcomes with patients' problem lists and treatment objectives, clinicians will identify areas of treatment needing improvement and formulate hypotheses for future research.

Orthodontic spring guidance of bilateral mandibular distraction in rabbits

Although distraction osteogenesis can lengthen congenitally small mandibles, the distraction procedure can be difficult to control. To study the efficacy and safety of orthodontic spring guidance on bilateral mandibular distraction, an 8-mm anterior open bite was experimentally produced and corrected during bilateral mandibular distraction in rabbits. Orthodontic springs were attached to the anterior maxilla and mandible to redirect an ongoing distraction procedure. Sixteen rabbits underwent mandibular distraction: 6 rabbits received heavy springs (8 oz), 6 rabbits received light force springs (2 oz), and 4 rabbits served as control animals with anterior open bites without spring guidance. Nickel-titanium springs were applied during the last week of osseous distraction and the first week of consolidation. Distractors were left in place throughout a 2-month consolidation period. None of the animals developed fibrous union as a result of spring guidance. The 8-mm open bite did not close in the control group or in the light spring group after 2 weeks of spring wear or during the consolidation period. Heavy springs completely closed the experimental open bites within 2 weeks (P <.01, analysis of variance). Bite corrections did not change during the consolidation period. This study indicated that the addition of an orthodontic spring to a mandibular distraction procedure did not impair bone healing. With the distraction device in place, heavy spring forces redirected an ongoing mandibular distraction procedure and corrected an open bite, distraction side effect. Direct measurements, radiographic measurements, and tissue histologic factors described changes in segment position and shape of the distraction site.