Int. J. Oral Maxillofac. Surg. 2012; 41: 37–41doi:10.1016/j.ijom.2011.09.001, available online at http://www.sciencedirect.com

Case Report

Cleft Lip and Palate

Interdental distractionosteogenesis for themanagement of alveolar clefts:archwise distraction

N. Erverdi, N. Kucukkeles, C. Sener, B. U. Selamet: Interdental distractionosteogenesis for the management of alveolar clefts: archwise distraction. Int. J. OralMaxillofac. Surg. 2012; 41: 37–41. # 2011 International Association of Oral andMaxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

0101-5027/01037 + 05 $36.00/0 # 2011 Inte

rnational Association of Oral and Maxillofacial Surge

N. Erverdi1, N. Kucukkeles1,C. Sener2, B. U. Selamet1

1Department of Orthodontics, MarmaraUniversity, Istanbul, Turkey; 2Department ofOral and Maxillofacial Surgery, MarmaraUniversity, Istanbul, Turkey

Abstract. Bone grafting is a successful protocol for cleft repair but it is verychallenging to close large gaps using local gingival tissue. In the last decade,interdental distraction osteogenesis has been introduced as a successful treatmentprotocol for repairing such large clefts. In this article a new method for closing thealveolar cleft is introduced and one case is presented. A tooth supported distractorwhich was specially designed to be inserted on to the main arch wire was used forthe distraction. The aim was to distract the tooth segments through the curve of thedental arch and achieve complete closure of the gaps. The distractor introduced hadseveral advantages: it is simple to apply, activate and remove; there is no need for asecond operation; it is an outpatient procedure. In the case reported, a very large gapwas successfully closed using this protocol whilst maintaining the ideal arch formand generating new bone behind the distracted segments.

Keywords: distraction osteogenesis; alveolarclefts; bone regeneration.

Accepted for publication 15 September 2011Available online 3 December 2011

Surgical closure of cleft defects is a chal-lenging procedure for the clinician. Bonegrafting is the usual, and successful, pro-cedure, which has been carried out formany years1,9,10. During bone grafting,the graft area should be covered properlyby the neighbouring gingival tissue. Whenthere is not enough gingival tissue aroundthe defect for restoration, surgeons tend touse a buccal soft tissue graft or tonguetissue graft to cover the bone graft. Bothtissues have a rich blood circulation, so aresuccessful for the primary maintenance ofthe bone graft tissue, but it is not possibleto move teeth along these tissues.

If the cleft is very large it is difficult toclose the gap using local gingival tissue.Recently, interdental distraction osteogen-esis has been introduced for repairingclefts larger than a canine tooth4–7. Themethod was used to decrease the size ofthe gap before grafting and performinggingivoperiosteoplasty.

In this article, a new method for closingthe alveolar cleft is introduced by describ-ing one case. A tooth supported distractor,specially designed for distraction throughthe curve of dental arch is introduced andthe clinical results of the procedure dis-cussed.

Case 1

The patient was a 22-year-old female whohad double jaw surgery 3 months pre-viously. She had Class I dental relation-ship, normal overjet and overbite and aunilateral residual alveolar cleft on theleft side. Upper left incisors and canine(21, 22 and 23) were congenitally absenton the clefted side and the gap was verylarge, extending towards the nasal floor(Fig. 1a and b). The surgeon had concernsabout the success of the grafting protocoland he proposed two interventions toachieve a better result. This led the

ons. Published by Elsevier Ltd. All rights reserved.

38 Erverdi et al.

authors to consider closing the gap usingalveolar distraction and the protocol wasdesigned accordingly. The upper arch wasbanded and bonded with 22 slot brackets.Other than first molars, bands wereadjusted and bonded for 12 and 13 toavoid bracket failure on these teeth. Theupper teeth were realigned and relevelleduntil 19 � 25 SS wires could be fullyinserted in the slots. An archwise distrac-tor designed by Erverdi (Tasarım Med,Istanbul, Turkey) was used for moving thealveolar segments. The body of the dis-

[(Fig._1)TD$FIG]

Fig. 1. Case 1: (a) Occlusal view of the arch befPanoramic radiography showing the cleft area.

tractor was made of titanium and the rodswere made of stainless steel. Every halfturn (180) of the screw equals 0.5 mmactivation and the maximum openingwas 13 mm. It was possible to achievelarger amounts of distraction with thesame device simply by closing the screwthen adding crimpable tubes on the sidesof the distractor and then reactivating thescrew.

Two distractors were placed on thearchwire between teeth 12 and 13 and25 and 26 (Fig. 2a). The plan was to

ore distraction. (b) Intraoral anterior view. (c)

distract the alveolar segment containingupper right central and lateral and thesegment containing upper left bicuspidstowards the cleft area until the segmentswere in contact. The patient was operatedon under general anaesthesia for theosteotomy of alveolar segments. Theminiplates that were close to the osteot-omy lines (that remained from previoussurgery) were removed during the surgi-cal intervention. The osteotomy was per-formed by making vertical cuts distal to12 and 25 on the vestibular buccal boneand extended until the palatal corticalbone and these vertical cuts were con-nected with a horizontal cut above theapices of the teeth. Piezo surgery wasused to avoid injury to the palatal perios-teum during the surgical procedure.Mobility of the segments was monitoredby activating the screw several times, andthen the screw was deactivated to theoriginal position.

The flaps were closed and the patientwas recalled after a 4 day latency period.The patient was instructed to open thescrew twice a day, each activation equal-ling 0.5 mm (1 mm total/day). The dis-traction was continued until the twoalveolar segments contacted each other(Fig. 2b). New bone was generated behindboth segments (14 mm on the right and11 mm on the left) through the distractionprotocol. Distraction lasted 20 days and atthe completion of distraction, both dis-tractors were fixed by adhesive and left insitu for 2 months for retention during theconsolidation of newly generated bone(Figs. 1c and 2c). The alveolar cleft areais measured two-dimensionally on thepre- and postoperative panoramic radio-graphs using Mimics software (MimicsV14.0 by Materialise, Belgium). The areaof the cleft region decreased by 60% post-distraction on two-dimensional measure-ments (dimensional differences betweenthe two radiographs was corrected usingproportionality) (Fig. 3a and b).

Discussion

During cleft palate repair bone grafting issuccessful, but soft tissue repair using themucosa or tongue creates problems aftersurgery. The gingival tissue is rich incollagen fibres and keratinized gingiva,which increases the resistance of the tissueto the pressures created during chewing.When the soft tissue coverings of the graftmaterial do not function like the attachedgingival tissue, the area is open to traumaand inflammation. Implant placement inthis type of tissue will result in periim-plantitis and failure.

Interdental distraction osteogenesis for the management of alveolar clefts: archwise distraction 39[(Fig._2)TD$FIG]

Fig. 2. Case 1: (a) Distractor in the mouth. (b) Occlusal view showing the undisturbed arch format the end of distraction. (c) New bone formation at the distraction sites.

Distraction osteogenesis is a uniquemethod for new bone generation and softtissue lengthening, which enables clini-cian to repair both soft and hard tissuesat the same time with the patient’s owntissues3,8. Many advantages have beenreported for the distraction of alveolarbone to close large cleft gaps4–6. It ispossible to decrease the size of the gapto a minimum which can be easilyrepaired. In the present case, the cleftregion decreased by 60% in surface area,measured from the radiographs. The 40%of bone cleft remains, but the cleft area hasbeen reduced enough for grafting. Com-

plete closure of the bony cleft could not beachieved because the tipping movement ofthe teeth in the distracted segments couldnot be prevented. Even though theimprovement of the bony cleft is limited,the soft tissue cleft is closed completelyand enough attached gingiva is formed tocover the bone graft.

Other advantages are that there is noneed for a donor site and donor site sur-gery, and very large gaps might be closedsuccessfully including new generatedbone which can be used to move teethinto. There are many distractors on themarket, such as bone borne, tooth borne

and hybrid types. The majority of thedistractors on the market are bone bornedevices so they perform the distractionthrough a straight line. This requires asecondary orthodontic treatment approachto create a symmetric and ovoid arch form.The advantage of the technique describedin this article is the transportation of thebony segment using a distractor attachedto the archwire so the bony segment istransported through the arch form. Using atooth borne distractor is also advantageousbecause it makes the protocol simpler byavoiding the surgery necessary forremoval of the distractor. Bands were usedon the teeth neighbouring the distractor toavoid bracket failure and 22 slot bracketswere preferred to increase the rigidity ofthe system and avoid friction during trans-portation of the segment.

In this protocol, the authors assume thatsmall linear distraction segments wereforced to occur through a curve, whichis a rigid archwire, and that these smalllinear distraction segments combine toform a curved shape. That is why theynamed it ‘archwise distraction’ (Fig. 4).

The only disadvantage of this protocolis locating posterior teeth in the anteriorregion during transportation. The authorsdistracted segments containing at least 2teeth for a successful result. LIOU & CHEN

4

recommended that distracted segmentsshould contain at least 2 teeth to ensurean adequate blood supply from the adjacentgingival or oral mucosa. The most frequentdistraction site is between the maxillaryfirst molar and the second premolar5,6. LIOU

& CHEN4 presented a similar protocol with a

bone borne distractor and reported 0.5 mmrelapse in the first 3 months after removal ofthe distraction device; the results werestable after 5 years4.

DING et al.2 studied changes in period-ontal tissue during maxillary dentoalveolardistraction osteogenesis using an intraoraltooth-borne distractor to close wide alveo-lar defects in four dogs. They found that themorphological changes in the periodontaltissues of the supporting tooth were mod-erate. They could be reversed if the rate andduration of distraction were correct like thephysiological changes of the periodontalligament of the orthodontic tooth. LIOU

et al. recommend moving the teeth intothe new generated bone as soon as possibleto avoid shrinkage during maturation5.

In conclusion, alveolar distractionseems to be a successful protocol forclosing large gaps in cleft cases. Thearchwise method is easy to apply andhas several advantages over the formermethods. The authors are aiming todevelop more rigid systems to prevent

40 Erverdi et al.[(Fig._3)TD$FIG]

Fig. 3. Measurements on the orthopantomogram of the cleft area (a) preoperative and (b) postoperative.

Interdental distraction osteogenesis for the management of alveolar clefts: archwise distraction 41[(Fig._4)TD$FIG]

Fig. 4. Drawing of small linear distraction segments that combine to form a curve following thearchform.

tipping of the teeth in the distracted seg-ments to close the alveolar bone cleft aswell as the soft tissue cleft.

Funding

This study is supported by Marmara Uni-versity Research Center (BAPKO) Projectnumber: SAG-D-300409-0138.

Competing interests

None declared.

Ethical approval

Not required. Personal authorisation of thepatients.

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Address:Nazan KucukkelesBelediye Sitesi A1 Blok No: 5AEtiler/IstanbulTurkey. Fax: +90 212 2323625; mobile: +905323222871E-mail: nazles@tnn.net