Microsoft Word - 216 2022.docx Alveolar ridge augmenta0on in mandible by use the modified distractor Vol 10 No 1 (2022) DOI 10.5195/d3000.2022.216 h#p://den*stry3000.pi#.edu Alveolar ridge augmentation in mandible by use the modified distractor Feras Sulaiman1, Issam Alkhouri1, Maher Al-assaf2 1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Damascus University, Damascus, Syria 2 Department of Oral Histology and Pathology, Faculty of Dentistry, Damascus University, Damascus, Syria Abstract OBJECTIVE: The aim of the present study was to evaluate the horizontal and the ver0cal alveolar distrac0on osteogenesis using modified alveolar distractor. STUDY DESIGN: The sample consisted of 7 pa0ents presen0ng horizontally and ver0cally deficient edentulous ridges were treated by distrac0on osteogenesis with a modified Alveolar distractor. The surgical procedure was carried out with the pa0ent under local anesthesia. A>er the osteotomy was performed with pizosurgery, the distractor was placed on the segmental bone over the gingiva for 3 months. The rate of distrac0on was 0.5 mm/twice a day. RESULTS: The mean of horizontal alveolar before using the distractor was 4.70 mm (SD 0.31 mm) The mean of horizontal alveolar a>er using the distractor was 8.30 mm (Sd 0.59 mm). The mean of actual gain in bone horizontal at the end of the distrac0on period was 3.58 mm (SD 0.15 mm). The mean of height alveolar before using the distractor was 6.67 mm (SD 0.46 mm) The mean of height alveolar a>er using the distractor was 12.59 mm (SD 0.52 mm). The mean of actual gain in bone height at the end of the distrac0on period was 5.92 mm (SD 0.25 mm). CONCLUSION: It was concluded that the modified alveolar distractor seems to be an effec0ve to treat horizontal and ver0cal alveolar ridge deficiencies, and distrac0on osteogenesis can be considered a safe and effec0ve procedure for gaining bone in the horizontal and the ver0cal dimension of the alveolar. KEYWORDS: horizontal alveolar; ver0cal alveolar; distrac0on osteogenesis; distractor Cita9on: Sulaiman, F et al. (2022) Alveolar ridge augmenta9on in mandible by use the modified distractor Den9stry 3000. 1:a001 doi:10.5195/d3000.2022.216 Received: August 2, 2021 Accepted: September 28, 2021 Published: May 9, 2022 Copyright: ©2022 Sulaiman F et al. This is an open access ar9cle licensed under a Crea9ve Commons ASribu9on Work 4.0 United States License. Email: dr.maher.assaf1990@gmail.com Introduction Some patients may have insufficient bone to place dental implants but there are many surgical techniques to increase the bone volume making implant treatment possible [1]. Bone can be regenerated in a horizontal and vertical direction using various techniques [2]. A variety of surgical techniques have been described to enhance the bone volume of deficient implant-recipient sites, such as the use of onlay or veneer grafts, ridge splitting, or bone condensation, guided bone regeneration (GBR), alveolar osteogenic distraction (AOD) [3,4]. Alveolar osteogenic distraction (AOD) has been considered a promising procedure for bone augmentation [5]. The AOD is a biological process through which new bone formation occurs between the surfaces of vascularized bone segments that are gradually separated by incremental traction [6]. The bone is initially Alveolar ridge augmenta0on in mandible by use the modified distractor Vol 10 No 1 (2022) DOI 10.5195/d3000.2022.216 h#p://den*stry3000.pi#.edu sectioned by osteotomy and the separation process is controlled by an osteodistractor device [5]. In this way, the AOD avoids the morbidity associated with the donor site and provides hard- and soft-tissue predictable gain once the alveolar bone gain occurs simultaneously with soft-tissue increase [3]. Moreover, the AOD is associated with low infection rate, decreased bone resorption, and a short period of bone healing, accelerating the treatment finalization [7]. The new bone structure formed by this technique has the same quality and morphology of the maxilla bone, and the use of the autogenous bone graft is not required [8]. AOD involves three phases: osteotomy/latency, activation/distraction and consolidation phases [9]. In general, we can distinguish 2 types of distraction devices: intraosseous and extraosseous [10]. They can also be differentiated depending on their role, dividing them into distractors or distractor-implants [11]. Depending on the direction of the regenerated bone, they are divided into vertical or horizontal distraction devices [12]. Different studies present different distraction protocols for each distractor device [13]. So, the aim of the research was to evaluate the horizontal and the vertical alveolar distraction osteogenesis using modified alveolar distractor. Material and Methods Study sample The research sample consisted of 7 patients presenting horizontally and vertically deficient edentulous ridges in the posterior mandibular region. Patients attending the dental implant unit and outpatient clinic of the department of oral and maxillofacial surgery at the Faculty of Dentistry at Damascus University. Inclusion criteria ü Ages of pa[ents from 20 to 55 years old. ü The pa[ents are healthy and do not have any general diseases. ü In pa[ents, the loss of one or more teeth in the posterior region of the mandibular. ü Pa[ents do not have any bad habits such as smoking or clinching. Exclusion criteria The availability of any of the following conditions is sufficient to exclude the patient from the research: ü The presence of general diseases or factors that prevent surgery under local anesthesia. ü Pa[ents with complete tooth loose of the mandibular. ü Pa[ents have bad habits such as smoking or clinching. ü Pregnancy. Surgical Procedure All patients were treated under local anesthesia (2% lidocaine solution with epinephrine 1:100.000). (Figure 2) Intraoral linear incision with 15C Scalpel Blade was performed on the vestibular region 1 mm above the mucogingival line. Then, one vertical incision rising from the first incision were carried out over the mesial region. A conservative subperiosteal dissection was performed to expose the bone ridge only in the osteotomy region. (Figure 3) Osteotomy was performed using a Figure 2. Initial intraoral image before the alveolar osteogenic distraction. Figure 3. The triangle flap. Alveolar ridge augmenta0on in mandible by use the modified distractor Vol 10 No 1 (2022) DOI 10.5195/d3000.2022.216 h#p://den*stry3000.pi#.edu piezoelectric ultrasonic device. (Figure 4,5) After performing an osteotomy in the alveolar bone, a distraction device is fixed on the transport segment and the basal bone over the gingiva. (Figure 6,7) Subsequently, the transport segment is submitted to gradual traction to separate it from the basal bone. The distraction devices were not activated for 7 days to allow periosteal and soft tissue healing and early vascularization. After a latency period of 7 days, distraction devices were activated 0.5 mm twice daily to achieve movement of 1 mm per day. After retention of 12 weeks, distractors were removed under local anesthesia. (Figure 8) A computed tomography (CBCT) image was performed for each case before the surgery procedure and the measurements were taken on the sections of the surgery site and the patient was followed up and after three months another CBCT was requested. (Figure 1,9) Statistical Analysis Statistical analysis was performed with SPSS (statistical package for the social sciences) v.25 (IBM, New York, NY). Statistical significance level was established at (p < 0.05). The paired t-test was used to evaluate bone dimensional changes (vertical and horizontal) between before and after the alveolar osteogenic distraction surgery. Results Study sample consisted of 7 patients, 1 male and 6 females and the age of the patients ranged between 20 - 55 years with a mean of 32.2 years. Bone Figure 4. The bone osteotomy by Piezo- surgery. Figure 5. The bone fragments. Figure 6. The suture. Figure 7. Placement of the modified alveolar distractor Figure 8. Final tissue volume obtained after 3 months of the alveolar osteogenic distraction surgery. Figure 9. CBCT radiograph after 3 months of the alveolar osteogenic distraction surgery confirming the bone gain obtained. Figure 1. Initial CBCT radiograph before the alveolar osteogenic distraction. Alveolar ridge augmenta0on in mandible by use the modified distractor Vol 10 No 1 (2022) DOI 10.5195/d3000.2022.216 h#p://den*stry3000.pi#.edu defects were different for each patient and bone ratio was set up depending on patient need. The evaluation of bone ratios was performed depending on the activating times of the distraction devices and supported by radiologic data. Distraction devices were activated twice a day (Table No. 1). The mean of horizontal alveolar before using the distractor was 4.70 mm (SD 0.31 mm) The mean of horizontal alveolar after using the distractor was 8.30 mm (Sd 0.59 mm). There was a statistically significant difference between timepoints (p < 0.05). The mean of actual gain in bone horizontal at the end of the distraction period was 3.58 mm (SD 0.15 mm) (Table No. 2 and Table No. 4). T-value P-value mean Difference S.D. of mean Difference Confidence interval (95%) Lower limit Upper limit Horizontal bone gain -25.922 .000 3.58- .150 -4.10 -2.89 Surgery Latency period Rate of bone elongation Consolidation period Device removal 7 days 0.5 mm/twice a day 3 months The width alveolar bone mean standard deviations Minimum Maximum Before distraction 4.70 .310 4.00 5.20 After distraction 8.30 0.59 4.00 9.50 Table 1: Protocol for gradual alveolar distraction osteogenesis of the posterior mandible prior to Device removal. Table 2: Means, standard deviations, and ranges of the width alveolar bone in the distraction osteogenesis (DO). Table 4: Paired T test for samples to study the change in the width of the alveolar bone before and after 3 months of the distraction osteogenesis (DO). Alveolar ridge augmenta0on in mandible by use the modified distractor Vol 10 No 1 (2022) DOI 10.5195/d3000.2022.216 h#p://den*stry3000.pi#.edu The mean of height alveolar before using the distractor was 6.67 mm (Sd 0.46 mm) The mean of height alveolar after using the distractor was 12.59 mm (SD 0.52 mm). There was a statistically significant difference between timepoints (p < 0.05). The mean of actual gain in bone height at the end of the distraction period was 5.92 mm (Sd 0.25 mm) (Table No. 3 and Table No. 5) Discussion Vertical and horizontal atrophy of the alveolar region may make implant placement difficult, thus compromising prosthetic rehabilitation [15]. Different augmentation techniques have been used for reconstruction of alveolar defects for many years, such as autogenous or artificial bone grafts and the split crest technique [16]. These conventional procedures have disadvantages, such as donor site morbidity, unpredictable bone resorption, and difficulty with soft tissue coverage [17]. ADO is an innovative procedure used to avoid donor site morbidity and problems with soft tissue coverage and limited augmentation [18]. The principals of distraction osteogenesis in which a gradual, controlled displacement of a surgically prepared fracture is used to increase bone volume, are not new but have recently been introduced into implant surgery to increase alveolar bone volume [19]. This study included 7 patients were treated by vertical and horizontal alveolar distraction osteogenesis. Alveolar ridge augmentation by DO has become the best alternative for preprosthetic surgery instead of using free, microvascular, and alloplastic bone grafts [20]. Reconstruction sites are filled with original bone and soft tissue reconstruction is managed at the same operation [9]. The Height alveolar bone mean standard deviations Minimum Maximum Before distraction 6.67 0.46 5.80 7.50 After distraction 12.59 0.52 11.70 13.40 T value P value mean Difference S.D. of mean Difference Confidence interval (95%) Lower limit Upper limit Vertical bone gain 51.765- .000 5.92- 0.25 6.17- 5.67- Table 3: Means, standard deviations, and ranges of the heigh alveolar bone in the distraction osteogenesis (DO). Table 5: Paired T test for samples to study the change in the height of the alveolar bone before and after 3 months of the distraction osteogenesis (DO). Alveolar ridge augmenta0on in mandible by use the modified distractor Vol 10 No 1 (2022) DOI 10.5195/d3000.2022.216 h#p://den*stry3000.pi#.edu Many authors have emphasized that distractors should not be activated for 5 to 7 days to allow callus formation [6]. During this time, a reparative callus is created, osteogenic cells proliferate, damaged blood vessels are repaired, and revascularization occurs [14,21]. In this study, we waited for 7 days to allow for callus formation, soft tissue, and periosteal healing. A gradual distraction rate of 0.5 mm twice a day [22]. In this way, we achieved painless stretching and appropriate adaptation of alveolar soft and hard tissues. ADO is an advantageous technique, providing both soft and hard tissue reconstruction with original structures. Taking into account the aspects of radiologic and histologic evaluations, the alveolar bone is considered to be appropriate to receive implants at the twelfth week [23]. The required time for dental implantation is shortened by this technique compared with classical procedures, so the consolidation phase was 12 weeks. Vertical augmentation is easy to evaluate using standard X-rays, while horizontal augmentation is difficult to evaluate with X-rays and CBCT is necessary. Recently, cone-beam CT (CBCT) has been widely used in dental treatment [24]. CBCT was used to assess bone height and width preoperatively, and finally after consolidation. At the end of the distraction procedures, radiolucent gaps were observed at the distraction chambers [25]. Twelve weeks after distraction, distraction gaps appeared mostly radio-opaque, but there were still some radiolucent areas. Evaluation of the dental CT scans, which were performed just before removal of the distractors (12 weeks after distraction), confirmed increase of the alveolar heights and widths and filling of the distraction chambers with bone. Esposito et al [4] in a systematic review of Cochrane on different vertical regeneration techniques, didn’t find sufficient evidence regarding which was the best procedure. However, they reported that the ADO technique has the greatest potential for vertical regeneration procedures. Conclusion With the limitation of this study, we can conclude that the modified alveolar distractor seems to be an effective to treat horizontal and vertical alveolar ridge deficiencies, and distraction osteogenesis can be considered a safe and effective procedure for gaining bone in the horizontal and the vertical dimension of the alveolar. If applied to patients selected carefully using preoperative CBCT, and if performed and managed accurately. References 1. Clinical outcomes of vertical bone augmentation to enable dental implant placement: a systematic review. Rocchietta I, Fontana F, Simion M. J Clin Periodontol. 2008 Sep;35(8 Suppl):203-215. doi: 10.1111/j.1600- 051X.2008.01271.x. PMID: 18724851. 2. The efficacy of horizontal and vertical bone augmentation procedures for dental implants: a Cochrane systematic review. Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. 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