CLINICAL
VERTICAL MANDIBULAR ALVEOLAR BONE
DISTRACTION AND DENTAL IMPLANT
PLACEMENT: A CASE REPORT
Miguel Peñarrocha-Diago, DDS,
PhD
M. Dolores Gómez-Adrián, DDS
Abel Garcı́a-Garcı́a, MD, PhD
Fabio Camacho-Alonso, DDS, DS
Javier Rambla-Ferrer, DDS
KEY WORDS
Bone distraction
Dental implants
Early loading
Distraction osteogenesis
Miguel Peñarrocha-Diago, DDS, PhD,
is an assistant professor of Oral Surgery
and director of the Master of Oral Surgery
and Implantology program,
M. Dolores Gómez-Adrián, DDS, is
a resident in the Master of Oral Surgery
and Implantology program, and Fabio
Camacho-Alonso, DDS, DS, and Javier
Rambla-Ferrer, DDS, are masters of Oral
Surgery and Implantology at Valencia
University Medical and Dental School in
Spain. Address correspondence to
Dr Peñarrocha-Diago, Gascó Oliag 1,
Unidad Médico-Quirúrgica, Clı́nica
Odontológica, 46021, Valencia, Spain.
Abel Garcı́a-Garcı́a, MD, PhD, is an
assistant professor of Oral Surgery and
director of the Master of Oral Surgery
and Implantology program at Santiago
de Compostela University Medical and
Dental School in Spain.
Extensive bone defects complicate the adequate placement of dental
implants and the required angulation. In such cases, alveolar-ridge
augmentation techniques such as guided bone regeneration, partic-
ulate or block grafting, and alveolar bone distraction are needed. The
present study describes a case in which a large vertical bone defect in
the anterior mandibular zone was corrected via vertical alveolar bone
distraction. Six dental implants were posteriorly placed for implant-
supported restoration of the mandible, with early implant loading.
The clinical and radiologic control showed good implant and soft
tissue conditions 12 months later.
INTRODUCTION procedure is needed, there is no
limit to lengthening, and simul-
ooth loss secondary
T
taneous lengthening of the sur-
to trauma or peri-
rounding soft tissues occurs.1
odontal disease or
A case is presented in which
as a result of con-
a large vertical bone defect in the
genital alterations
anterior mandibular zone was
produces a loss of
corrected via vertical alveolar
alveolar ridge height and width.
bone distraction. A total of 6
In such cases, esthetic and func-
dental implants were placed, 3
tional implant-supported reha-
in the distracted segment, which
bilitation requires the use of
allowed for complete implant-
techniques designed to augment
supported restoration of the man-
the atrophic alveolar ridge. 1
dible.
Guided bone regeneration and
particulate, or en bloc, grafting
are among the traditional tech-
niques used to achieve such
CLINICAL CASE
augmentation. However, bone
distraction offers an alternative A 44-year-old woman with a hep-
approach for the management of atitis C virus infection and a his-
large-bone defects.2,3 Distraction tory of facial trauma in childhood
osteogenesis has some advan- (ie, loss of the right eye, several
tages. In effect, no additional teeth, and part of the anterior
surgery involving a harvesting mandibular ridge) presented for
Journal of Oral Implantology 137
ALVEOLAR DISTRACTION AND IMPLANTS

138 Vol. XXXII / No. Three / 2006

 Miguel Peñarrocha-Diago et al

implant-supported mandibular
rehabilitation. Clinical intraoral
examination revealed significant
anterior mandibular bone and
vestibular atrophy (Figure 1).
There was approximately 6 cm
of mesiodistal alveolar deficiency
and 2 cm of vertical deficiency.
The patient had a fixed prosthesis
replacing her anterior maxillary
teeth. Orthopantomography (Fig-
ure 2) and computerized axial
tomography confirmed the pres-
ence of adequate alveolar bone
for osteogenesis distraction of
the anterior mandible.
The surgical procedure was
completed using local anesthesia
(2% articaine with adrenaline
1:100 000). A full-thickness, trap-
ezoidal flap was reflected from
3.5 to 4.6. A rounded drill was
used to mark the bone between
the mental foramina for distrac-
tion. A divergent rhomboid os-
teotomy of the vestibular cortical
and spongy components was
then performed with tungsten
carbide discs, fracturing the lin-
gual cortical layer with a mallet
and chisel. The Lead System
(Stryker Leibinger, Freiburg, Ger-
many) was used for distraction.
After bone-fragment mobilizing,
a drill was used to prepare the
distractor bed in the distraction
fragment and remaining bone.
Because the bone segment was
longer than 2 cm, 2 distractor
screws were positioned with their
respective plates. The distractor
screw traversed both plates
through one of their orifices, and
these were affixed to the bone by
osteosynthesis screws. The base
plate was positioned in the lower bone fragment. The remaining
zone with fixation to the mandib- teeth were then extracted and
ular bone, while the distractor the distraction screws were re-
plate was affixed in the upper moved. The dimensions of the
zone and to the mobile-bone implants and the Ostell values
fragment (Figures 3 and 4). Con- obtained at the time of surgery
tinuous, simple, triple-zero silk are shown in Table 1. All implants
sutures were placed (Figure 5). were left submerged.
Amoxicillin was prescribed (750 Second-stage surgery was per-
mg 3 times a day for 7 days), formed 2 months later and, after
along with ibuprofen 600 mg healing of the mucosa (1 month
during 4 days and 0.2% chlorhex- later), the cemented, fixed pros-
idine rinses. The stitches were thesis was placed and yielded an
removed after 7 days. acceptable esthetic outcome and
After 12 days, distraction of good radiologic adjustment (Fig-
the alveolar segment was started ures 7 through 9). The clinical and
at a rate of 1 mm daily (ie, a single radiologic control 24 months later
turn of the screw daily). In the showed good implant and soft
first 3 days, the patient reported tissue conditions (Figure 10).
to the clinic for distraction and
then continued the process at
home with following clinic visits. DISCUSSION
Following the 15 days of activa-
tion, the resulting bone augmen- Extensive bone defects in the
tation was evaluated (Figure 6). anterior mandible complicate the
During the distraction-consol- location and angulation for den-
idation period, an anteroinferior tal implanting. The patient in this
vestibuloplasty was carried out to report presented with a large
increase the vestibular depth. Un- vertical bone defect of the
der local anesthesia (2% articaine anteroinferior alveolar ridge that
with adrenalin 1:100 000), an in- was treated with alveolar bone
cision was made in the alveolar distraction. This technique facili-
crest from canine to canine. A tates bone and soft tissue pro-
partial-thickness flap was raised
to the vestibular fundus, where
suturing to the periosteum was TABLE 1
carried out. The exposed zone Implant dimensions and
was covered with Surgicel. Ostell values at surgery
The implants were placed 12 Diameter Length Ostell
weeks after the completion of Location (mm) (mm) (ISQ)
distraction. We first positioned 6 32 4.20 16.0 44
Defcon TSA implants (Impladent, 34 4.20 16.0 68
36 5.50 13.0 78
Sentmenat, Barcelona, Spain) 42 4.20 16.0 69
with Avantblast surfacing to 44 4.20 16.0 66
prevent collapse of the distracted 46 5.50 11.5 70

FIGURES 1–10. FIGURE 1. Alveolar atrophy of the lower incisor, canine, and premolar regions. FIGURE 2. Preoperative panoramic X-ray
view. FIGURE 3. Two distractor screws are positioned with their respective plates, with fixation of the latter using titanium
miniscrews. FIGURE 4. Panoramic X-ray view of the distraction device in place. FIGURE 5. Suture and occlusal verification to avoid
distractor-screw contact with the upper teeth in maximum occlusion. FIGURE 6. After 15 days of activation, the resulting bone
augmentation was evaluated. FIGURE 7. Obtainment of impressions. FIGURE 8. Facial view of cemented prosthetic rehabilitation 3
months after implant placement. FIGURE 9. Occlusal view of cemented prosthetic rehabilitation 3 months after implant placement.
FIGURE 10. Panoramic X-ray view showing the cemented implant-supported fixed prosthesis 24 months after placement.

Journal of Oral Implantology 139

ALVEOLAR DISTRACTION AND IMPLANTS
Alveolar bone distraction: latency, activation rate, duration of activation, and consolidation period
Authors, Latency
year (d)
Gaggl et al, 20009 7–10
Chiapasco et al, 200110 7 1 (0.5 mm every 12 h)
Uckan et al, 20025 7 0.8 (0.4 mm every 12 h)
Uckan et al, 20027 7 0.8
Feichtinger et al, 200311 7 0.25–0.5
liferation through distraction or
stretching of pre-existing native
bone. No donor-site surgery is
required, and there is no limit to
elongation. Distraction increases
soft tissues (ie, skin, mucosa,
blood vessels, muscle, nerves) as
well as bone,4 and there is a lesser
tendency toward bone resorp-
tion.5 The disadvantages of
distraction are the prolonged pe-
riod of distraction5 and the need
for maintaining strict control of
segment bone direction during
distraction.4 The success rates of
implant placed in distracted
alveolar bone ranges from 85%
to 97%.6,7
According to Ley and Cranin,2
the success of alveolar bone dis-
traction depends on a series of
factors, including: (1) osteogenic
tissue preservation, (2) stabiliza-
tion of the distractor screws and
plates, (3) an adequate latency
period, (4) an appropriate rhythm
and rate during the distraction
period, and (5) observation of the
required consolidation period. It
is essential to preserve the blood
supply to the distracted seg-
ments. An incision on the crest
with reflection of a full-thickness
buccal flap was used to preserve
the soft tissue supply to the bone
segment. Stabilization of the dis-
tractor elements is essential for
correct bone-block movement.
We used 2 distractors according
to Garcia-Garcia et al,8 who rec-
ommend this approach when bone
blocks are longer than 2 cm in
length. The latency, activation rate,
140 Vol. XXXII / No. Three / 2006
TABLE 2
Activation Duration of Consolidation
rate (mm/d) activation (d) period (mo)
0.25–0.5 8–24
— 2–3
11–13
— 3
8–24
duration of activation, and con-
solidation period in alveolar bone
distraction vary according to dif-
ferent authors (Table 2).5,7,9–11
Distraction was started 12 days
after surgery at a rate of 1 mm
daily.
An important treatment de-
cision is the timing of implant
placement. Block et al12 found
that the space between the base
bone and distracted bone block
was filled within 6 to 8 weeks.
The main characteristic of this
new bone was the presence of
mature lamellar bone and osteo-
blasts, which indicated active
bone formation. According to
Degidi et al,13 the optimum mo-
ment for implant placement is
10 to 16 weeks after the active
phase of distraction has been
completed. In this case, the im-
plants were placed after 12 weeks
of consolidation.
According to Chin,14 the im-
plants should be left submerged
for 5 months, with prosthesis
placement after second-step sur-
gery. However, at present, new
implant surfaces make it possible
to shorten the treatment times
required for implant-supported
prosthetic rehabilitation. Dedigi
et al13 combined alveolar bone
distraction with immediate load-
ing and obtained satisfactory re-
sults after 12 months of follow up.
In this case, implant loading was
started early (90 days after place-
ment), thereby shortening the
treatment time and improving
patient comfort.
No. of patients and
distraction zone
4–6 35 (mandible and upper jaw)
8 (7 mandible, 1 upper jaw)
3 3 (mandible)
10 (2 mandible, 8 upper jaw)
4–6 35 (mandible and upper jaw)
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