CLINICAL CASE Dent. Med. Probl. 2006, 43, 3, 447–451 ISSN 1644−387X

© Copyright by Silesian Piasts University of Medicine in Wrocław and Polish Stomatological Association

HANNA GERBER1, JAN NIENARTOWICZ1, WOJCIECH PAWLAK1, ZDZISŁAW WOŹNIAK2

Bi−Directional Distraction Osteogenesis of the Alveolar Bone – Preliminary Report Dwukierunkowa osteogeneza dystrakcyjna wyrostka zębodołowego – doniesienie wstępne 1 2

Department of Maxillofacial Surgery University of Medicine, Wrocław, Poland Department of Pathological Anatomy University of Medicine, Wrocław, Poland

Abstract Alveolar bone traumatic loss is a big reconstructive problem. Trauma causes both loss of alveolar bone and soft tissues of the area. The authors present new methods of alveolar bone process reconstruction with the use of bi− directional osteogenesis distraction. Bone deficiency regeneration is presented as a result of bi−directional distrac− tion performed with Medartis V2 distracting device which allows the control of distraction direction both vertical− ly and lingually−labially. Histology of alveolar bi−directional reconstruction is described. Advantages of bi−direc− tional distraction in osseous and soft tissues problems treatment avoiding additional surgical intervention are emphasized (Dent. Med. Probl. 2006, 43, 3, 447–451). Key words: alveolar bone traumatic loss, bi−directional distraction osteogenesis.

Streszczenie Pourazowa utrata kości wyrostka zębodołowego jest poważnym problemem rekonstrukcyjnym. Uraz powoduje utra− tę zarówno kości wyrostka, jak i tkanek miękkich w tej okolicy. Autorzy przedstawiają nowe metody odbudowy ko− ści wyrostka zębodołowego z wykorzystaniem dwukierunkowej osteogenazy dystrakcyjnej. Opisana regeneracja ko− stna jest wynikiem dwukierunkowej dystrakcji za pomocą dystraktora Medartis V2 pozwalającego kontrolować kie− runek dystrakcji zarówno pionowo, jak i językowo−wargowo. Przedstawiono dowód histologiczny dwukierunkowej rekonstrukcji wyrostka. Należy podkreślić zaletę dwukierunkowej dystrakcji w leczeniu ubytków kostnych i tkanek miękkich w postaci uniknięcia dodatkowego zabiegu chirurgicznego (Dent. Med. Probl. 2006, 43, 3, 447–451). Słowa kluczowe: pourazowa utrata kości wyrostka zębodołowego, dwukierunkowa osteogeneza dystrakcyjna.

Since the introduction of distraction osteogen− esis to reconstruct facial bone, alveolar process osteogenesis has been regarded an alternative method of osseous defects before patient’s sched− uled prosthetic rehabilitation. Bi−directional dis− traction osteogenesis is a course of alveolar process new bone formation to correct both its height and lingual and labial vector which is espe− cially important on planning further treatment with intraosseous implants as the precise installation in the bony base in the correct position is indispens− able [1–3]. A major problem in alveolar process distrac− tion is the tendency of osteotomy fragment to dis− locate palatally in the maxilla or lingually in the

mandible. Such a displacement direction is caused by the fact that buccal periosteum is incised in order to reach osteotomy required access whereas lingual periosteum remains intact and its continu− ity is indispensable to provide appropriate supply of the osteotomized bone fragment. Besides, lin− gual displacement is caused by thick and non elas− tic mucous membrane of the palate. In atrophic mandible, it seems the result of muscles traction in the oral cavity floor [4–7]. Conventional one− directional distractors allow bone reconstruction only in vertical dimension. After using one−direc− tional device, initially selected distraction direc− tion cannot be corrected during the treatment [8–10]. Hence, multi directional osseous distrac−

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tion is a significant progress in bone defects recon− struction. Since 2000, the trials had been made to construct and use clinically bi−directional distrac− tion system. Bi−directional device is fixed to vestibular surface of the mandible body with the use of mini plates and screws. The device is com− posed of titanium and has two cylinders. One of them is used for vertical distraction and the other enables anterior−posterior dislocation of the bone defect. In this way, angulation of maximum 40° is possible. In vertical direction, one turn gives 0.25 mm distraction [4, 10]. The goal of the paper is presentation of the possibility of mandibular alveolar process recon− struction with the use of bi−directional distracting device.

Case Report Female patient N.O. aged 26 (case history No 801/04) was transported to the Maxillofacial Surgery Dept. by an ambulance on 23.08.2004 at 3 a.m. from a road accident after previous skull CT and neurosurgical consultation. Clinical examina− tion revealed: unconscious female patient, intratra− cheally intubated, left cheek injuries penetrating to oral cavity, lacerated and bleeding wound of upper lip, nasal dorsum skin wounds. Intraoral cavity examination showed: scalped mandible body from the left angle area to 45 tooth area, comminuted fracture of the mandibular alveolar process with its crushing and avulsion of teeth 44, 43, 42, 41, 31. There were also open fracture of the mandible body on the left side as well as break of the artic− ular process of the mandible on the right side, breaking of teeth 12, 22, 21 crown, left and right eyes haematoma, sutured and dressed wound of the right forearm. The patient developed respirato− ry insufficiency due to the presence of clots in intubation tube and dysrythmia was found. The patency of intubation tube was restored and when her general condition was put under control, the patient was qualified to emergency surgery. Oral cavity and face wounds were debrided under gen− eral anaesthesia. Mandible body underwent repo− sitioning and plate osteosinthesis. Mandibular alveolar process in 44–31 teeth area was dressed. After the surgery, the patient was referred to the Intensive Care Unit of Wrocław University of Medicine Hospital. Having regained consciousness, the patient underwent the procedure of dressing the condylar process fracture with splints with intermaxillary fixation and occlusion conditions reconstruction. After several months, the patient was admitted to The Maxillofacial Surgery Dept. (case history No

611/05) to undergo the treatment of traumatic alve− olar bone loss in mandible with the use of bi−direc− tional distractor by Medartis (Figs. 1, 2). Under general anaesthesia and intratracheal intubation, in the oral cavity vestibule, after intraoral incision, the plate previously used for mandibular body fracture osteosynthesis was removed. Tooth 31 was extract− ed due to the root complete exposure. Then, in seg− ment 44–32, marginal osteotomy of mandibular alveolar process was performed. Osseous segment 5 mm high was formed and it was pedunculated on mucous and periosteal flap (Fig. 3). The courses of vertical osteotomies were 1 mm distant from adja− cent teeth and slightly convergent with horizontal osteotomy. All osteotomies were performed with a saw. Distracting device was adapted 15 mm and fixed by screws (diameter 1.5 mm) on the bone vestibular surface (Fig. 4). Steering cylinders were introduced to the oral cavity and the distractor was untwisted (Fig. 6). The whole was covered with mucous and periostial flap (Fig. 7). Postopera− tively, antibiotics were administered for 5 days. After 10 days (resting stage), the stitches were removed and active distraction was started to be

Fig. 1. Photograph reveals post traumatic deficiency of alveolar ridge and loss of teeth Ryc. 1. Fotografia przedstawia deficyt kości wyrostka zębodołowego oraz braki zębowe po urazie, a przed zabiegiem dystrakcji

Fig. 2. Pantomographic X−ray before distraction Ryc. 2. RTG przed zabiegiem dystrakcji

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Fig. 3. Mucoperiosteal flap reflected and osteotomy lines visible Ryc. 3. Stan po wytworzeniu płata śluzówkowo−okost− nowego. Przedstawiono linie osteotomijne

Fig. 6. Activation of distraction device Ryc. 6. Etap rozkręcenia dystraktora w celu uwidocz− nienia zaplanowanego efektu leczenia

Fig. 4. Adaptation of distraction device Ryc. 4. Dostosowanie dystraktora

Fig. 7. Mucoperiosteal flap sutured and vector control cylinders visible Ryc. 7. Stan po przykryciu dystraktora płatem śluzów− kowo−okostnowym (widoczny element regulujący)

Fig. 5. Mobilization of osteotomized segment Ryc. 5. Mobilizacja odłamu kostnego

Fig. 8. Pantomographic X−ray after distraction Ryc. 8. RTG po ukończeniu leczenia dystraktorem

continued at a rate 0.5 mm a day for 30 days. When expected vertical height was achieved, gradual seg− ment inclination was performed until the angle of 15° was gained. Alveolar process bone reconstruc−

tion of 15 mm was achieved and the chip was posi− tioned in vestibular direction (Fig. 8). After 8 weeks, the distracting device was removed in local anaesthesia. Simultaneously,

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Fig. 9. Histologic appearance of tissues harvested from the distraction regenerate at 2 month of consoli− dation. Active osteoblasts are present on the surface of thin, immature, woven bone (H&E × 20 and right lower corner H&E × 200) Ryc. 9. Obraz histologiczny tkanki pobranej z regene− ratu w drugim miesiącu po zakończeniu dystrakcji. Na uwagę zasługują osteoblasty widoczne na powierzchni cienkich niedojrzałych beleczek kostnych (H&E × 20 i w prawym dolnym rogu H&E × 200)

newly reconstructed bone was harvested from the distraction gap for histopathological examination. Radiologically, the consolidation of new bone was observed in the distraction gap after 6 weeks.

Discussion Alveolar bone deficiency results from peri− odontal diseases, tumours, trauma or congenital defects. At present, there are various opinions con− cerning indications for distraction or reconstruction based on osseous materials or autogenous grafts. In distractive osteotomy, osteotomized bone fragment is lifted by distractive device. The required height of osteotomized bone must be at least 4–5 mm and

the space for distractor fixation. If these conditions cannot be met, bone graft reconstruction method is preferable. Another factor which largely influences the treatment method is the condition of mucous membrane. In the cases of tooth loss resulting from trauma or infection, the healing process often caus− es tension scar formation. If, then, bone grafts are performed, there is often difficulty with covering the transplant with mucosal soft tissue. After sutur− ing, mucous membrane, at the stitches site, under− goes increased tension and very often, wound dehiscence occurs which can cause infection and even graft loss [4, 11, 12]. Distraction osteogenesis method makes the mucous membrane gradual stretching by the movement of distracted bone segment. Consequently, secondary mucous membrane changes eliminate the need for additional soft tis− sue procedures [4, 12, 13]. Presented bi−directional distraction system enables vertical distraction and also allows the vector change in buccal−labial directions which seems very important on plan− ning further implant treatment. The above factors suggest that bone segmental deficiency after teeth loss is a good indication for bi−directional distrac− tion osteogenesis [4]. Histological examination of a bone newly formed in bi−directional distraction system. In unidirectional distraction osteogenesis, lately developed bone in distraction gap area con− sists of rods which reveal parallel alignment. The density of a newly formed bone is low and the maturation process can take even months [4, 14, 15]. Authors’ own examinations show bone high density of complex architecture. Numerous ce− mentum lines are indicative of the bone strong remodelling activity and ongoing maturation process (Fig. 9). This histopathological examina− tion result shows that bone favourable regenera− tion is the result of combination of vertical dis− traction and gradual anterior angulation of the bone fragment.

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Address for correspondence: Jan Nienartowicz Department of Maxillofacial Surgery Silesian Piast University of Medicine in Wrocław Chałubiński 5 50−368 Wrocław Poland tel.: +48 071 748 22 61 e−mail: [email protected] Received: 17.05.2006 Revised: 6.09.2006 Accepted: 6.09.2006 Praca wpłynęła do Redakcji: 17.05.2006 r. Po recenzji: 6.09.2006 r. Zaakceptowano do druku: 6.09.2006 r.