Int. J. Oral Maxillofac. Surg.

2007; 36: 6–10

doi:10.1016/j.ijom.2006.06.014, available online at http://www.sciencedirect.com

Clinical Paper
Pre-implant Surgery

A retrospective study of the R. Mazzonetto, M. Allais,

P. E. Maurette, R. W. F. Moreira
Department of Oral and Maxillofacial Surgery,

potential complications during Piracicaba Dental School. Campinas State

University, Piracicaba - São Paulo, Brazil

alveolar distraction
osteogenesis in 55 patients
R. Mazzonetto, M. Allais, P. E. Maurette, R. W. F. Moreira: A retrospective study of
the potential complications during alveolar distraction osteogenesis in 55 patients.
Int. J. Oral Maxillofac. Surg. 2007; 36: 6–10. # 2006 International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this retrospective study was to analyse the outcome of alveolar
distraction osteogenesis for the correction of vertical defects in a large series of 55
cases. The existing bone deficiencies were secondary to atrophy after periodontal
disease or tooth extraction. The overall success rate of this technique was 89.1%.
The complications presented during treatment were divided into minor (no effect on
final result, but immediate intervention required) 14/55 patients (25.4%), and major
(lead to technique failure) 6/55 patients (10.9%). The frequency of minor
complications was 8/27 in the anterior maxillary region, 1/27 in the anterior
mandibular region and 15/27 in the posterior mandibular region. The frequency of
major complications was 5/6 in the posterior mandibular region and 1/6 in the
anterior maxillary region. The mean alveolar height achieved was 6 mm. The
overall rate was 36.3%. On the basis of these results it was concluded that alveolar
distraction osteogenesis is an effective technique to treat vertical alveolar ridge Accepted for publication 20 June 2006
deficiencies. Available online 12 December 2006

Alveolar distraction osteogenesis (ADO)
was introduced by CHIN & TOTH in 19962,
and is gaining acceptance as a surgical
technique for increasing alveolar bone
where rehabilitation with dental implants
is required7,12,16. Compared with the con-
ventional techniques of bone grafting and
guided bone regeneration, ADO offers the
advantages of decreased bone resorption,
lower rate of infection and no donor site
morbity7,21, and tissue is gained7,8,16. The
disadvantages include difficulty in con-
trolling the segments, lack of patient coop-
eration and the need for more office visits,
and the cost of the device5,6,19,23.
During the distraction process, compli-
cations include resorption of the transport
segment, difficulty in completing the
osteotomy on the lingual side, excessive
length of the threaded rod and device
failure11,14,19. Postoperative complica-
tions include incorrect direction of distrac-
tion (tipping of transport segment),
perforation of the mucosa by the transport
segment, and inadequate length of distrac-
tion5,7,11,14,19. The purpose of this study
was to present the results of a large series
of patients who underwent ADO.
Patients and methods
From March 2001 to March 2003, 55
patients (38 females and 17 males) were

0901-5027/0106 + 05 $30.00/0 # 2006 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 A study of the complications during alveolar distraction 7

treated with ADO for the correction of a

deficient alveolar ridge, using an extra-
alveolar device (Conexão1, Implant Sys-
tem, São Paulo, Brazil). The mean age of
the group was 33.5  10.9 years old. The
alveolar defects were caused by atrophy
after tooth extraction, creating either an
anatomical or aesthetic obstacle to the
successful delivery of dental implants.

Surgical technique
All operations were performed under local
anaesthesia by the same surgeon. After a
horizontal incision was made in the vesti-
bule, a buccal mucoperiosteal flap was
elevated to expose the lateral cortex.
The crestal mucosa was not elevated.
The footplates were adapted to the
patient’s alveolar ridge. The transport seg-
ment was then osteotomized as an inverted
trapezoidal shape with discs, sagittal saws
and chisels. The transport segment was
totally mobilized but the lingual mucoper-
iosteum remained attached. The device
was positioned and fixed into place with
1.5-mm monocortical screws. After acti-
vation to test its function, the device was
returned to its initial position. The flap was
closed with a 4.0 Vicryl suture (Johnson &
Johnson, Ethicon1, Brazil).
Distraction protocol
After a latency period of 7 days, a distrac-
tion rate of 0.33 mm every 8 h (1 mm per
day) was achieved for 6–12 days, accord-
ing to the planning for each particular
case. After 90 days, the device was
removed and implants were placed. If
additional width was required, bone graft-
ing was performed at the time of device
removal and implants were placed 5
months later. Six months after implant
placement prosthetic restoration was
achieved.
Fig. 1. Length of distraction before activation (LD1); radiographs taken 1 day before start of
device activation.
Clinical follow-up was performed on
days 7, 10, 15, 20, 30, 60 and 90 after
device placement. Panoramic radiographs
were taken on days 7, 20 and 90 after
surgery. Long-term radiographs were also
taken 3 and 6 months after device removal.
To measure bone gain two panoramic
radiographs were taken, one immediately
before surgery and the other at the end of
the consolidation period (12 weeks post-
operatively). The magnification factor
(MF) was determined by dividing the real
size of the activation rod (RS) by the
image size of the activation rod (IS).
The vertical bone gain (VGB) was calcu-
lated by first measuring the length of dis-
traction before activation (LD1), i.e. the
distance between the superior portion of
the basal plate and the superior portion of
the transport plate multiplied by the MF
(Fig. 1). Then, the length of distraction
after activation (LD2), on radiographs
taken 12 weeks postoperatively, was mea-
sured in the same way (Fig. 2). The VBG
was obtained using the following formula:
VBG = LD2 LD111.
Results
Fifty-five patients underwent alveolar dis-
traction. The regions are summarized in
Table 1. In 49/55 patients treated, the
planned distraction height was achieved
and implants were placed. The mean bone
height gained was 7.4 mm (anterior max-
illa region), 4.4 mm (posterior mandible
region), 6 mm (anterior mandible region)
and 6.3 mm (posterior maxilla region),
with an overall mean of 6 mm (range 0–
10.83). The increased radiopacity of the

Evaluation
Complications were categorized into two
groups: minor complications, i.e. those
that did not affect the final result but
required immediate attention; and major
complications, i.e. those that lead to fail-
ure of the technique. Minor complications
included tipping of the bone transport
segment, dehiscence, infection, lack of
patient collaboration and perforation of
the mucosa by the transport segment.
Major complications included resorption
of the bone transport segment, device fail-
ure, fracture of the mandible, non-union,
dysesthesia of the mental nerve, and
inadequate length of distraction. Fig. 2. Length of distraction after activation (LD2).
8 Mazzonetto et al.

Table 1. Classification of the resorbed areas

that were treated by ADO
No. of
Anatomic region cases Percentage
Posterior mandible 28 51
Anterior maxilla 22 40
Anterior mandible 3 5
Posterior maxilla 2 4
Total 55 100

distracted area could be observed from 3

to 6 months after the procedure. In 21/55
(38%) patients, it was necessary to aug-
ment the site with an autogenous bone
graft: 17/21 (80.9%) in the anterior max- Fig. 3. Scar tissue after 10 weeks of ADO.
illary region, 3/21 (14%) in the posterior
mandibular region and 1/21 (5%) in the Table 2. Major complications
anterior mandibular region.
In 6/55 patients (10.9%) there were Frequency Total
Region (no. of cases) (no. of cases)
seven major complications: lack of device
activation (3/55), epithelium invagination Lack of device activation Posterior mandibular region 2 3
(1/55), non-union (1/55) (Fig. 3), fracture Anterior maxillary region 1
of transport disc (1/55) and failure of Epithelium invagination Posterior mandibular region 1 1
device (1/55). The frequency of major Non-union Posterior mandibular region 1 1
complications was 5/6 in the posterior Fracture of transport disc Posterior mandibular region 1 1
mandibular region and 1/6 in the anterior Total 6
maxillary region (Table 2).
In 14 patients (25.45%) there were 27
minor complications including infection In 38% of patients it was necessary after lar ridge is a well-known phenomenon,
(8/55), paresthesia (6/55) (posterior mand- ADO to augment the site with an auto- termed hour-glass deformity17,18. GARCIA
ible), tipping of transport disk (3/55) genous bone graft, principally in the et al.4 analysed the ridge-bone morphol-
(Fig. 4), hyperplasia (3/55) (anterior max- anterior maxillary region (80.9%). Post- ogy of 12 patients who underwent a total
illary region; Fig. 5), fracture of the screw distraction lateral concavity of the alveo- of 17 alveolar ridge distraction procedures
(2/55), incomplete osteotomy requiring
revision (1/55), and inadequate height
(wrong device) (1/55). The frequency of
minor complications was 8/27 in the ante-
rior maxillary region, 1/27 in the anterior
mandibular region and 15/27 in the poster-
ior mandibular region (Table 3).

Discussion
The ADO is a relatively new method that,
when compared to onlay grafts or guided
bone regeneration, offers the benefits of
decreased morbidity and bone resorption,
and concurrently enables the lengthening
of soft tissues and vessels by histiogen-
esis2,7,8,12,13,16,21. In this case series, the
mean vertical bone gain was 6 mm and the
implant success rate was 92%. This is
comparable with the results of other stu-
dies reported in the literature5,8,13,15.
ADO offers advantages over other crest
reconstruction techniques, but some com-
plications can occur during the activation
phase or postoperative period5,19. In this
study a large number of cases (55) were
treated with ADO with a high success rate
(89.1%). Success was defined by the
length of the alveolar ridge after treatment. Fig. 4. Excessive tipping of transport disk.
 A study of the complications during alveolar distraction
Fig. 5. Hyperplasia in the anterior maxillary region.
before implant placement. They made a vestibular depth and a predictable verti-
preliminary morphologic classification of cal bone increase to ensure a vascular
the alveolar ridge after distraction osteo- bed for the bone graft, making the treat-
genesis, and concluded that bone forma- ment more predictable13. The growth of
tion during the process is not always the soft tissue permits improved closing
spatially uniform and predictable, with of the wound after the second operation
obvious implications for subsequent (to place the bone graft), reducing ten-
implant placement. This was found mainly sion considerably, and avoiding dehis-
in the anterior maxillary region, with cence and consequent loss of the bone
severe vertical and horizontal atrophy. graft5,10. In this study, the cases where it
Similar findings have been reported by was necessary to combine the two tech-
BLOCK et al.1, KARP et al.9 and MAZZONETTO niques were not considered failures,
& TOREZAN14, who verified that in close to because the advantages of ADO were
20% of cases there are bone defects that obtained, and the aesthetic result was
require a new bone distraction process or better than if only an autogenous bone
bone grafts for correction. graft had been used.
URBANI et al.22 observed that the buccal The most common minor complication
bone cortex in the distracted region was was tipping of the transport segment; this
thinner than the lingual cortex. Likewise, is consistent with other studies10,11,14.
ODA et al.15 explain that there is less bone During maxillary AOD, the distracted seg-
formation in the facial than in the lingual ment may incline palatally due to the thick
region due to trauma caused by the inci- and inelastic palatine mucosa. In the
sion and osteotomy, particularly to the mandible, lingual muscles such as the
periosteum. KLUG et al.10 explain the use mylohyoid may push the segment lin-
of titanium membranes in the distraction gually10,11. UCKAN et al.20 reported a sim-
region to obtain better bone formation. ple orthodontic treatment to reposition the
JENSEN et al.8 and GARCIA et al.5 reported distracted segment, inserting the implants
that of the seven regions operated four appropriately after realignment. To reori-
presented bone defects that needed minor ent the segment, digital pressure during
graft bone procedures. the distraction period was used. In the
In such cases ADO can be applied to maxillary case, this was not possible and
gain soft tissue without alteration of the an onlay bone graft from the mental region
Table 3. Minor complications
Frequency Total
Region (no. of cases) (no. of cases)
Infection Anterior maxillary region 3 8
Posterior mandibular region 5 the alveolar ridge after distraction osteo-
Paresthesia Posterior mandibular region 6 6
Tipping of transport disk Posterior mandibular region 3 3
Hyperplasia Anterior maxillary region 3 3
Dehiscence Anterior maxillary region 3 3
Fracture of screw Posterior mandibular region 1 1
Fracture of devicea Anterior maxillary region 1 1
Osteotomy revision Anterior maxillary region 1 1
Inadequate length Anterior mandibular region 1 1
Total 27
a
Necessary alveolar height was still achieved.
9
was performed. This case was not consid-
ered a failure because secondary recon-
struction with a bone graft had been
planned preoperatively. There was one
case of fracture of a distractor device
during the activation period, probably
due to excessive bending and manipula-
tion. This complication was considered
minor, because the necessary alveolar
height was achieved. GABRIELE et al.3
and UCKAN et al.20 also reported the frac-
ture of a miniplate distractor due to an
error made during adaptation of the
device. Dehiscence and plate exposure
were found in three maxillary cases, but
did not affect the functional or aesthetic
results. Daily rinsing of the area with
chlorhexidine solution was the recom-
mended treatment.
Among the major complications were
three bone-formation defects and one frac-
ture of the transport segment mandible.
All three patients were treated with auto-
logous bone grafting and bone-guided
regeneration. There was neither clinically
observed infection nor resorption of the
superior aspect of the alveolar ridge. ADO
is an effective technique to treat vertical
alveolar ridge deficiencies. Although com-
plications are frequent, they are usually
easy to resolve. Very close follow-up is
required.
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Address:
Renato Mazzonetto
Faculdade de Odontologia de Piracicaba
Av. Limeira 901
Centro Cirúrgico
Bairro Arelhão
Piracicaba-SP
CEP 13414-903
Brazil
Tel: +55 19 3412 5389
Fax: +55 19 3412 5218
E-mail: renatomz@fop.unicamp.br