distraccion alveolar rev
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Alveolar distraction osteogenesis vs.vertical guided bone regeneration for thecorrection of vertically deficient
edentulous ridges: A 13-yearprospective study on humans
Matteo ChiapascoEugenio RomeoPaolo Casentini
Lia Rimondini
Authors affiliations:Matteo Chiapasco, Paolo Casentini,
Unit of Oral SurgeryEugenio Romeo, Unit of ProsthodonticsLia Rimondini, Unit of Oral Medicine, Departmentof Medicine, Surgery, and Dentistry, San PaoloHospital, University of Milan, Italy
Correspondence to:Dr Matteo ChiapascoDental BuildingVia Beldiletto 1/320142 MilanoItalyTel.: 39 02 50319000Fax: 39 02 50319040e-mail: [email protected]
Key words:alveolar distraction osteogenesis, Dental implants, e-PTFE membranes, guided
bone regeneration
Abstract:The purpose of this prospective study was to compare vertical guided bone
regeneration (GBR) and vertical distraction osteogenesis (DO) for their ability in correcting
vertically deficient alveolar ridges and their ability in maintaining over time the vertical
bone gain obtained before and after implant placement. Eleven patients (group 1) were
treated by means of vertical GBR with autogenous bone and e-PTFE membranes, while 10
patients (group 2) were treated by meansof DO.In group 1, six patients received implants at
the time of GBR (subgroup 1A), while five patients had implants placed at the time of
membrane removal (subgroup 1B). In group 2, implants were placed at the time of
distraction device removal. A total of 25 implants were placed in group 1 and 34 implants
were placed in group 2 patients. Three to 5 months after implant placement, patients were
rehabilitated with implant-borne dental prostheses. The following parameters were
evaluated: (a) bone resorption of the regenerated ridges before and after implant
placement; (b) peri-implant clinical parameters 1, 2, and 3 years after prosthetic loading of
implants; (c) survival and success rates of implants. Bone resorption values before and after
implant placement were significantly higher in group 1. The results suggested that both
techniques may improve the deficit of vertically resorbed edentulous ridges, although
distraction osteogenesis seems to be more predictable as far as the long-term prognosis of
vertical bone gain is concerned. Implant survival rates as well as peri-implant clinical
parameters do not differ significantly between the two groups, whereas the success rate of
implants placed in group 2 patients was higher than that obtained in group 1 patients.
Dental rehabilitation of partially or totally
edentulous patients with dental implants
has become common practice in the last
decades with reliable long-term results
(Albrektsson et al. 1986; Albrektsson
et al. 1988; Adell et al. 1990; Laney et al.
1991; Lekholm et al. 1994; Lindquist
et al. 1996; Buser et al. 1997; Arvidson
etal. 1998; Weberetal. 2000; Leonhardtet al.
2002). However, local conditions of the
edentulous alveolar ridges may be unfavor-
able for implant placement. In particular, a
relevant vertical defect of the alveolar ridge
may render the use of dental implants
difficult or impossible due to an insuffi-
cient bone volume to harbor implants of
adequate dimensions. To correct this situa-
tion, a variety of surgical procedures have
been proposed, such as onlay bone grafts,
vertical guided bone regeneration (GBR),
and alveolar distraction osteogenesis (DO).
The reconstruction of vertically atro-
phied ridges with onlay bone grafts was
the first procedure to be used and today
there is ample documentation in terms of
number of cases treated and follow-up of
implants placed in the reconstructed areas
(Breine & Branemark 1980; Keller et al.Copyrightr Blackwell Munksgaard 2004
Date:
Accepted 25 March 2003
To cite this article:
Chiapasco M, Romeo E, Casentini P, Rimondini L.Alveolardistractionosteogenesis vs. verticalguided boneregeneration for the correction of vertically deficientedentulous ridges: a 13-year prospective study onhumans.Clin. Oral Impl. Res.15, 2004; 8295
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1987; Listrom & Symington 1988; Kahn-
berg et al. 1989; Nystrom et al. 1993;
Donovan et al. 1994; Keller 1995; William-
son 1996; Brusati et al. 1997; Lundgren
et al. 1997; Chiapasco et al. 1998). How-
ever, results reported are non-homoge-
neous, due to the unpredictable bone
resorption that may occur before and after
implant placement. Moreover, the reported
data are difficult to compare due to the
different donor sites of autogenous bone
(intraoral sites, calvaria, tibia, iliac crest)
and due to the different systems used for
the evaluation of implant survival and
success rates (Weingart & Petrin 1999).
Vermeeren et al. (1996) reported very
unfavorable results of mandibular onlay
grafts, attributable to the severe bone
resorption that occurred after bone grafting
and the relevant peri-implant bone resorp-
tion after implant placement and prostheticloading. Another disadvantage may include
the need for bone harvesting from intraoral
or extraoral sites, with increased morbidity,
operating times, and duration of hospitali-
zation. Therefore, clinical research has
been oriented towards other alternatives,
such as vertical GBR with semipermeable
barriers (Simion et al. 1994; Jovanovic et al.
1995; Simion et al. 1998; Cornelini et al.
2000; Simion et al. 2001). The rationale of
this technique is based on long-term results
obtained from implants inserted in hori-zontally augmented bone ridges, demon-
strating that semipermeable barriers
allowed an undisturbed healing of the bone
transplant in a secluded space, thus redu-
cing significantly the risk of bone resorp-
tion (Dahlin et al. 1991, 1995; Nevins &
Mellonig 1992; Lang et al. 1994; Buser
et al. 1990, 1996).
The clinical experience on vertical GBR
is limited if compared to that concerning
horizontal augmentation, but promising
results have been presented (Simion et al.
1994; Jovanovic et al. 1995; Tinti et al.
1996; Simion et al. 1998,2001). In a recent
retrospective multicenter study by Simion
et al. (2001), 49 partially edentulous pa-
tients presenting 53 vertically deficient
sites were treated with vertical bone
augmentation by means of e-PTFE
membranes. Forty-nine patients received
implants at the time of the augmentation
procedure, whereas the remaining four pa-
tients were treated with a staged approach.
A total of 123 implants were inserted.
Complications such as abscesses and mem-
brane exposures occurred in nine out of 49
patients (18.4%), while the cumulative
survival rate of implants was 97.5%. The
authors concluded that this technique is
reliable and the vertically augmented bone
with GBR techniques responded similar to
native, non-regenerated bone. It must be
stressed, however, that Rasmusson et al.
(1999) demonstrated extensive bone resorp-
tion of the regenerated bone after mem-
brane removal. The study concluded that a
barrier may help preserve bone grafts as
long as the barrier is in place, whereas the
entity of bone resorption after its removal
was similar to that occurring in the case of
bone grafting without membranes.
Alveolar DO is another method used to
correct vertically atrophied alveolar ridges.
Originally applied in the orthopedic field
(Ilizarov 1975; Codivilla 1905), it has beenextended more recently to correct maxillo-
facial deformities such as Franceschetti
syndrome, hemifacial microsomia, etc.,
(McCarthy et al. 1992; Molina & Ortiz-
Monasterio 1995; Carls & Sailer 1998) and,
since 1996, it has been suggested to correct
vertical defects of the alveolar ridges (Block
et al. 1996, 1998; Chin and Toth 1996;
Hidding et al. 1998; Chiapasco et al 2000,
2001, 2002; Nocini et al. 2000; Urbani
2001; Raghoebar et al. 2000; Consolo et al.
2000; Robiony et al. 2002; Jensen et al.2002). Preliminary results seem to be very
promising: however, the reported data are
difficult to compare, due to the different
systems used for the evaluation of implant
survival and success rates.
Thus, despite a relevant number of
publications concerning these different
techniques, much controversy still exists
as far as the choice of the more reliable
technique is concerned, and, to the authors
knowledge, no comparative studies among
these techniques have been published yet.
The aim of this prospective study was to
compare vertical GBR and vertical DO for
their ability in correcting vertically defi-
cient alveolar ridges and their ability in
maintaining over time the vertical bone
gain obtained around implants.
Material and methods
In a 3-year period (19982000), 21 systemi-
cally healthy individuals, nine males and
12 females, aged between 18 and 59 years
(mean: 39.8 years), who presented with
vertical alveolar ridge defects were selected
for surgical correction of the deficit to
improve implant support, the crown-to-
implant ratio, and the final esthetics of
implant-borne prostheses constructed in
the edentulous areas.
Patients exclusion criteria were: (a)
vertical defects of the edentulous ridge
associated to a severe knife-edge ridge; (b)
bone defects following tumor resection; (c)
tobacco abuse (more than 15 cigarettes per
day); (d) severe renal and liver disease; (e)
history of radiotherapy in thehead andneck
region; f) chemotherapy for treatment of
malignant tumors at the time of the
surgical procedure; (g) non-compensated
diabetes; (h) active periodontal disease
involving theresidual dentition; (i) mucosal
disease, such as lichen planus in the areasto be treated; (j) poor oral hygiene; (k) non-
compliant patients.
Routine radiographic documentation of
the treated patients was obtained with: (a)
panoramic and intraoral radiographs taken
preoperatively, immediately after the re-
generative procedure or application of the
distractor, at the end of the distraction
procedure, at the time of the implant
placement, at the time of prosthetic reha-
bilitation, and annually thereafter.
The 21 patients were randomly assignedto two different groups. Group 1 patients
(11 patients) were treated by means of
vertical GBR with e-PTFE titanium rein-
forced barriers (Gore-Texs
, W.L. Gore and
Associates, Inc., Flagstaff, AZ, USA) and
particulated autogenous bone taken from
intraoral sites (chin and/or ramus of the
mandible). Group 2 patients (10 patients)
were treated by means of alveolar DO with
an intraoral extraosseous distraction device
(Gebruder Martin GmbH & Co., KG,
Tuttlingen, Germany). Randomization
was concealed to the surgeon until the
surgical procedure.
Surgical procedure for group 1 patients
Vertical GBR was performed under local
anesthesia in six patients, under local
anesthesia with intravenous sedation (dia-
zepam 0.2 mg pro/kilo) in three patients,
and under general anesthesia with nasotra-
cheal intubation in two patients. The type
of anesthesia was chosen according to
Chiapasco et al . Alveolar DO vs. vertical GBR
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extension and site of the defect, accessi-
bility, predetermined duration of the pro-
cedure, and patient compliance.
The procedure started with a midcrestal
incision on the edentulous ridge with
mesial and distal releasing incisions accord-
ing to surgical needs. In case of residual
dentition on the mesial or distal aspect of
the surgical field, the horizontal incison
was continued in the gingival sulcus,
involving one or two adjacent teeth. A
full-thickness mucoperiosteal flap was
then elevated, the bone defect exposed,
and connective tissue remnants were re-
moved. Cortico-cancellous autogenous
bone blocks were then harvested from
intraoral sites. The mandibular ramus was
the site of first choice for bone harvesting.
Only in two cases, where larger amounts of
bone were needed, bone harvesting was
performedfrom both thesymphysis andtheramus. The bone blocks were then particu-
lated with a bone mill, to facilitate graft
adaptation to the defect. The cortical bone
of the recipient bed was then perforated
with a 1-mm diameter round bur to
increase blood supply from endosseous
vessels to the transplanted bone. In six
out of the 11 patients treated (subgroup
1A), 13 Branemark system implants were
inserted immediately, with the guidance of
preformed surgical templates. The implant
shoulder was placed in an ideal position
from theprosthetic viewpoints, leaving part
ofthe implant to protrude 27 mm from the
bone level. In these cases, endosseous
implants acted as supporting and tenting
devices forthe membrane. In theremaining
five patients (subgroup 1B), one or two
titanium microscrews, 1.5 mm in diameter
and 713 mm long, were left to protrude 4
7 mm from the bone level and used to
support/tent the membrane. In this sub-
group, implants were inserted at the time of
membrane removal. A staged procedure
was used whenever a risk of insufficient
primary stability of implants was subjec-
tively expected.
Defects that remained around implants
or screws were packed with autogenous
bone chips and covered with a titanium
reinforced e-PTFE stabilized with titanium
fixating pins (Frioss
by Friadent, GmbH,
Mannheim, Germany) and/or microscrews(Gebruder Martin GmbH & Co., KG,
Tuttlingen, Germany). Flaps, after perios-
teally releasing incisions to obtain a ten-
sion-free closure, were accurately sutured
with e-PTFE 4-0 sutures.
All patients received 3 g of ampicillin per
day, starting approximately 1 h before
surgery and continuing for 6 days after
surgery) and non-steroidal analgesics post-
operatively. Postoperative instructions in-
cluded a soft diet for 2 weeks and
appropriate oral hygiene with 0.2% chlor-
hexidine mouthrinse. In case of intrave-
nous sedation or general anesthesia, anti-
biotics were administered intravenously at
the time of induction and then continued
orally for 6 days.
Sutures were removed 710 days post-
operatively. Removable prostheses were
not allowed in the reconstructed areas until
membrane removal. In case of pre-existing
bridges or adhesive provisional prostheses
(Maryland bridges), provisional prostheses
anchored to adjacent teeth were fabricated
to reduce patient discomfort, but special
care was dedicated to avoid any contact
between the prosthesis and the soft tissues
overlying the reconstructed areas.
In subgroup 1A, membranes and retain-
ing minipins or microscrews were removed
67 months after surgery, implant abut-
ments connected and the prosthetic reha-
bilitation was initiated.In subgroup 1B, membranes and retain-
ing minipins or microscrews as well as the
screws used for supporting membranes
were removed 67 months after surgery,
and 12 Branemark system implants were
inserted according to surgical templates.
Three to 5 months after implant place-
ment, implants were uncovered and the
same procedure described for subgroup 1A
was followed. Anagraphic data and clinical
features of patients, number and type of
implants are reported in Tables 1 and 2.
Table1. Anagraphic data and clinical features of subgroup 1A Vertical GBR with immediate placement of implants
Pt.
number
Age
(years)
Date of
stage-1
surgery
Date of
abutment
connection
Number and
type of implants
Implant
length (mm)
Implant
site
Site of bone
harvest
Mean bone
gain at stage-1
surgery (mm)
Complications
#1 51 Jan-98 Jun-98 1 Branemark 13 45 Ramus 4.0 No
1 Branemark 13 46 3.0
#2 47 Feb-98 Jul-98 1 Branemark 13 36 Ramus 7.0 Membrane exposure infection1 Branemark 13 37 7.0
#3 49 Jun-98 Oct-98 1 Branemark 11.5 44 Ramus 5.0 No
1 Branemark 11.5 45 5.0
1 Branemark 11.5 46 4.0
#4 57 Jan-99 Jun-99 1 Branemark 15 43 Ramus 5.0 Membrane exposure
1 Branemark 15 41 3.01 Branemark 15 32 2.5
#5 44 Apr-99 Oct-99 1 Branemark 13 44 Ramus 4.0 No
1 Branemark 13 45 5.0
#6 31 Apr-99 Nov-99 1 Branemark 15 11 Ramus 4.0 No
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Surgical procedure for group 2 patients
The DO procedure was performed under
local anesthesia in three patients, under
local anesthesia with intravenous sedation
(diazepam 0.2 mg pro/kilo) in five patients,
and under general anesthesia with naso-
tracheal intubation in the remaining two
patients. The procedure started with an
intraoral incision in the buccal vestibule,
without lateral releasing incisions. Carefulsubperiosteal dissection was performed to
obtain adequate visibility of the underlying
bone, but no mucoperiosteal dissection was
performed toward the alveolar crest and on
the lingual/palatal side to preserve adequate
blood supply to the bone segment to be
osteotomized. A preplating and modelling
of the intraoral distractor (Gebruder Martin
GmbH & Co., KG, Tuttlingen, Germany)
was performed before the osteotomy. With
an oscillating saw and/or a fissure bur, the
bone segment to be vertically distracted
was completely separated from the basal
bone. Once the osteotomy was completed,
the intraoral distractor was fixated to both
the basal bone and the osteotomized seg-
ment with 1.5-mm large titanium micro-
screws (Gebruder Martin GmbH & Co.,
KG, Tuttlingen, Germany). The osteoto-
mized segment to be distracted was im-
mediately moved by activating the
distractor to check the direction of distrac-
tion and freedom in movements. Finally,
the osteotomized segment was repositioned
at its initial position and the surgical access
was sutured with 4-0 sutures.
Antibiotics, non-steroidal analgesics,
diet, and oral hygiene regimens followed
the same protocol used in group 1 patients.
After a waiting period of 7 days for
closure of the surgical wound, sutures were
removed and the activation of the distrac-
tion device was started. A distraction of
1 mm per day (subdivided into two activa-
tions of 0.5 mm every 12 h) was performeduntil the desired amount of distraction was
obtained (range: 49 mm). The distractor
was then maintained in position for 23
months to obtain maturation of the
neocallus formed between the basal bone
and the distracted segment. After this
waiting period, the distractor was removed
and endosseous implants were placed
following the prefabricated surgical
templates.
A total of 34 titanium screw-shaped
endosseous implants were placed in the
distracted segments (eight patients received
28 Branemark system implants and two
patients received six screw-type ITI im-
plants). After to 36 months, abutments
were connected to the implants and the
prosthetic treatment was initiated.
Only one surgeon (MC) performed all the
reconstructive and implant placement
procedures for both groups. Anagraphic
data and clinical features of patients,
number and type of implants are reported
in Table 3.
Parameters evaluated andfollow-up for groups 1 and 2patients
The following parameters were evaluated
by a calibrated examiner: (a) radiographic
assessment of bone resorption between the
GBR procedure and the time of implant
placement (subgroup 1B) and between the
end of DO and the time of implant
placement; (b) radiographic assessment ofperi-implant bone resorption before and
after implant loading; (c) radiographic as-
sessment of peri-implant clinical para-
meters 1, 2, and 3 years after prosthetic
loading; (d) implant survival and success
rates.
Radiographic assessment of bone resorp-tion between GBR (subgroup 1B) and thetime of implant placement and DO pro-cedures and the time of implant placement
In subgroup 1B, this parameter was eval-
uated by comparing periapical radiographs
taken immediately after the GBR procedure
and immediately before implant place-
ment. The bone level obtained at the end
of the GBR procedure was considered the
baseline for the following measurements.
Measurements were taken on each micro-
screw with a transparent millimeter ruler,
measuring the distance between the top
of the screw head and the most coronal
level of direct bone-to-screw contact. The
Table2. Anagraphic data and clinical features of subgroup 1B vertical GBR with delayed placement of implants
Pt.
number
Age
(years)
Date of
stage-1
surgery
Date of
stage-2
surgery
Date of
abutment
connection
Number and
type of
implants
Implant
length
(mm)
Implant
site
Site of
bone
harvest
Mean bone
gain at stage-1
surgery (mm)
Complications
#1 28 Jan-98 July-98 Nov-98 1 Branemark 15 13 Ramus 4.0 No
#2 39 Feb-98 Sept-98 Feb-99 1 Branemark 13 23 Ramus chin 6.0 Paresthesia of
chin area1 Branemark 13 24 5.0
1 Branemark 13 25 4.0
#3 30 Jun-99 Dec-99 Apr-00 1 Branemark 15 23 Ramus 5.0 No
1 Branemark 13 24 4.0
#4 59 Sept-99 Apr-00 Sept-00 1 Branemark 13 12 Ramus 5.0 No1 Branemark 15 13 4.5
1 Branemark 13 14 4.0
#5 45 Feb-00 Sept-00 Jan-01 1 Branemark 11.5 44 Ramus chin 7.0 Paresthesia of chinarea and Membrane
exposure
1 Branemark 10 45 6.5
1 Branemark 10 46 6.0
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measurements were taken to the nearest
0.5 mm.
In group 2, this parameter was evaluated
by comparing periapical radiographs taken
at the end of distraction and at the time of
implant placement and the distance fromthe upper margin of the osteotomized
segment and the upper margin of the
distractor plate. The measurements were
taken to the nearest 0.5 mm.
Radiographic assessment of peri-implantbone resorption after implant placement
Peri-implant bone resorption was recorded
by comparing periapical radiographs taken
immediately after implant placement, at
the time of prosthetic loading, and then
annually. Measurements were made mesial
and distal to each implant by means of a
transparent millimeterruler, measuring the
distance between the top of implant head
shoulder and the most coronal level of
direct bone-to-implant contact. The bone
level measured on periapical radiographs
takenimmediately afterimplant placement
was considered the baseline for further
measurements. The measurements were
recorded to the nearest 0.5 mm.
Peri-implant clinical parameters
Modified plaque index (MPI) and modified
bleeding index (MBI) were recorded at four
sites of each implant (mesial, distal, buccal,
lingual/palatal) (Mombelli et al. 1987).
Probing depth (PD) measurements were
performed at four sites of each implant
(mesial, distal, buccal, lingual/palatal) to
the nearest millimeter using a calibrated
plastic probe (TPS Probes
by Vivadent - FL
9494 Schaan, Liechtenstein). Measure-
ments were recorded every 12 months after
the initial prosthetic loading.
Implant success and survival rates
Successful implants can be characterized by
the following criteria: (a) absence of persis-
tent pain or dysesthesia; (b) absence of peri-
implant infection with suppuration; (c)
absence of mobility; (d) absence of contin-
uous peri-implant radiolucency; and (e)
peri-implant bone resorption less than
1.5 mm in the first year of function and
less than 0.2 mm in the following years
(Albrektsson et al. 1986).
Criteria for implant survival may include
absence of persistent pain or dysesthesia,
absence of peri-implant infection with
suppuration, absence of mobility, absence
of continuous peri-implant radiolucency,
but with peri-implant bone resorption
greater than the values proposed by Al-
brektsson et al. (1.5 mm in the first year of
function and less than 0.2 mm annually inthe following years).
Statistical analysis
Homogeneity of variance were tested with
the Levene test. Because Levene test was
significant, the Kruskal-Wallis ANOVA
exact test with the Monte Carlo method
to compute probability was applied to
multiple comparisons.
Because of lack ofpost hoctest for non-
parametric ANOVA, the MannWhitney
U-exact test was used for two sample
comparisons (group 1A vs. group 1B; group
1A vs. group 2; group 1B vs. group 2). the
Monte Carlo method was used to compute
probability.
ResultsGroup 1 patients
Recovery of donor sites in group 1 was
uneventful in all cases of bone harvesting
Table3. Anagraphic data and clinical features of group 2 patients distraction osteogenesis
Pt.
number
Age
(years)
Date of
stage-1
surgery
Date of
stage-2
surgery
Date of
abutment
connection
Number and
type of
implants
Implant
length
(mm)
Implant site Mean bone
gain at stage-1
surgery (mm)
Complications
#1 27 Jan-98 Apr-98 Oct-98 1 Branemark 11.5 45 8.0 No
1 Branemark 10 46 8.0
#2 20 Mar-98 Jun-98 Nov-98 5 Branemark 15 4443413334 7.0 No
#3 37 May-98 Oct-98 Feb-99 4 ITI 12 41323335 7.0 No
#4 33 Feb-99 May-99 Nov-99 4 Branemark 13 13141516 7.0 No
#5 42 Apr-99 Jun-99 Nov-99 2 ITI 12 4546 4.0 No
#6 18 Nov-99 Feb-00 May-00 3 Branemark 13 424344 6.0 No
2 Branemark 10 4536 6.0
#7 19 Feb-00 May-00 Oct-00 2 Branemark 15 4231 6.0 Lingual inclination
bone fragment
#8 55 Mar-00 Jun-00 Nov-00 4 Branemark 15 44423234 9.0 No
#9 46 Jun-00 Sep-00 Feb-01 3 Branemark 10 343536 6.0 No
#10 39 Jul-00 Oct-00 Jan-01 3 Branemark 13 444546 5.0 Lingual inclination
bone fragment
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from the mandibular ramus. A transient
paresthesia of the lower lip occurred in two
patients who underwent bone harvesting
from the chin, lasting 1 and 4 weeks,
respectively. A paresthesia to the frontal
mandibular teeth was also present in bothcases, but in one of these (patient
#5subgroup 1B), this symptom, although
reduced, is still present 2 years after
surgery.
Recovery of the reconstructed sites was
uneventful in eight patients. Early exposure
of the membrane occurred in three patients.
For patient #5 of subgroup 1B membrane
became exposed 3 weeks after suture
removal. Despite oral antibiotic therapy
and local antispetic control (0.2% chlor-
hexidine mouthrinse 3 times/day plus
topical chlorhexidine gel, persistent sup-
puration remained that resulted in early
removal of the membrane at 4 weeks
postoperatively. Although bone regenera-
tion in this patient was partially compro-
mised (3-mm bone resorption after a gain of
6.5 mm), implants placed in these compro-
mised conditions still achieved osseointe-
gration after 4 months of healing. These
implants remained in function even after
18 months. For patient # 2 of subgroup 1A,
membrane exposure and suppuration oc-
curred 10 weeks after the GBR procedure.
Although the membrane was immediately
removed, a significant amount of granula-
tion tissues were found beneath the mem-
brane. Despite infection, implants were
clinically stable and were left in place. Atthe time of abutment connection, intraoral
radiographs demonstrated a perimplant
bone loss ranging from 3 to 3.5 mm (initial
bone gain7 mm). Three years after the
start of implant loading, despite a bone loss
ranging from 4 to 4.5mm and threads
exposed, implants and the suprastructure
are still clinically stable. For patient #4 of
subgroup 1A, early exposure of the mem-
brane occurred 8 weeks after suture re-
moval, with no clinically evident sign of
infection. Therefore, the patient was trea-
ted only with application of topical
chlorhexidine gel for 5 months, until
membrane removal and abutment connec-
tion. No exposure of implant threads was
found.
The mean follow-up from the start of
prosthetic loading of group 1A and 1B
implants was 41 months (range: 3048
months) and 29 months (range: 1848
months), respectively. All patients in this
group had acceptable function of the im-
plant-borne prostheses, with no pathologic
signs or symptoms such as paresthesia,
dysesthesia, pain, etc.
The mean peri-implant bone resorption
between implant placement and abutment
connection, between abutment connection
and 13 years after the start of prostheticloading in group 1A were 1.27mm
(SD0.8), 1.83 mm (SD1.0), 1.88 mm
(SD0.9), and 2.06 mm (SD0.9), respec-
tively. Medians and quartile ranges are
reported in Table 4.
The mean bone resorption beforeimplant
placement in subgroup 1B was 1.35 mm
(SD0.9). The mean peri-implant bone
resorption between implant placement and
abutment connection, between abutment
connection and 13 years after the start of
prosthetic loading in group 1B were
0.69 mm (SD0.3), 1.29 mm (SD0.4),
1.52 mm (SD0.3), and 1.69 mm (SD
0.3), respectively. The total bone resorption
at the end of the observation period (the
sum of measurements before and after
implant placement) was 2.96mm
(SD1.1). Medians and quartile ranges
are reported in table 4.
In group 1A, the mean MPI values at 1,
2, and 3 years after the start of prosthetic
loading were 0.31 (SD0.6), 0.40 (SD
0.6), and 0.35 (SD0.5), respectively.
Table4. Comparison of bone resorption in group 1A, 1B, and 2 before and after implant placement
Time
interval
Patient
group
Mean
(mm)
SD Median First
quartile
Third
quartile
Min
range
Max
range
Kruskal
Wallis ANOVA
P-values
MannWhitney
U-test P-values
BRIP GBR (1B) 1.35 0.9 1.0 1.0 2.0 0.5 3.0 < 0.01 1A vs. 1B P
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The mean MBI values at 1, 2, and 3 years
were 0.22 (SD0.5), 0.20 (SD0.4), and
0.26 (SD0.4), respectively. The mean PD
values at 1, 2, and 3 years were 2.16mm
(SD0.7), 2.49mm (SD0.9), and
2.68mm (SD0.8), respectively.
In group 1B, the mean MPI valuesat 1, 2,
and 3 years after the start of prosthetic
loading were 0.34 (SD0.6), 0.38
(SD
0.4), and 0.30 (SD
0.6), respec-tively. The mean MBI values at 1, 2, and
3 years were 0.24 (SD 0.4), 0.22
(SD0.4), and 0.29 (SD0.5), respec-
tively. The mean PD values at 1, 2, and 3
years were 2.73mm (SD0.9), 2.75 mm
(SD0.8), and 2.67 mm (SD0.8), respec-
tively.
None of the patients in groups 1A and 1B
dropped out of the follow-up and no
implants were lost in both subgroups, but
five out of 13 implants in group 1A and
three out of 12 implants in group 1B
presented peri-implant bone resorption
values higher than those for implant
success proposed by Albrektsson et al.
(1986). Thus, cumulative survival and
success rates of implants placed in group
1A patients at the end of the follow-up
period were 100% and 61.5%, respec-
tively (Table 5). In group 1B these
values were 100% and 75%, respectively
(Table 6).
A case treated with the vertical GBR
principle is presented in Figs 17.
Table5. Group 1A (GBR and immediate implants) life table analysis showing cumulative survival and success rates of implants
Interval Implants
at start of
interval
Withdrawn
implants
Failing
implants
Implants
under risk
at the end
of interval
Cumulative
survival rate (%)
Cumulative
success rate (%)
Placement to loading 13 0 2 13 100 84.6
Loading to 1 year 13 0 2 13 100 84.6
12 years 13 0 3 13 100 76.9
23 years 13 3 5 10 100 61.5
Failing implants implants with bone resorption > 1.5 mm after the first year of loading and > 0.2 mm in the following years but fulfilling the other criteria
of Albrektsson et al.
Table6. Group 1B (GBR and delayed implants) life table analysis showing cumulative survival and success rates of implants
Interval Implants at
start of
interval
Withdrawn
implants
Failing
implants
Implants under
risk at the
end of interval
Cumulative
survival rate
(%)
Cumulative success
rate (%)
Placement to loading 12 0 0 12 100 100
Loading to 1 year 12 0 2 12 100 83.3
12 years 12 0 2 12 100 83.3
23 years 12 8 3 4 100 75
Fig.1. Preoperative situation showing loss of 43424131 and vertical defect of the alveolar ridge.
Fig.2. Preoperative panoramic radiograph showing relevant bone loss in the area corresponding to 434241.
Chiapasco et al . Alveolar DO vs. vertical GBR
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Group 2 patients
Recovery of the surgical sites was unevent-
ful in all cases. In two patients (patients #7
and #10), a progressive lingual inclination
of the distracted segment occurred during
distraction, probably due to the traction on
the osteotomized segment by muscle forces
on the floor of the mouth. To avoid a
consolidation of the distracted segment in
an unfavorable position, an orthodontic
traction was applied to the distracted
segment. The orthodontic appliance was
maintained until consolidation of the neo-
callus in the desired position was reached.
No other adverse effects were encountered.
The mean follow-up from the start of
prosthetic loading was 31 months (range:
1854 months). All patients in this group
referred acceptable function of the implant-
borne prostheses with no pathologic signs
or symptoms such as paresthesia, dysesthe-
sia, pain, etc.
The mean bone resorption between the
end of DO and the time of implant
placement was 0.37 mm (SD0.4). The
mean peri-implant bone resorption be-
tween implant placement and abutment
connection, between abutment connection
and 13 years after the start of prosthetic
loading were 0.50 mm (SD0.4), 1.13 mm(SD0.3), 1.24mm (SD0.3), and
1.41mm (SD0.3), respectively. The total
bone resorption at the end of the observa-
tion period (the sum of measurements
before and after implant placement) was
1.93mm (SD0.7). Medians and quartile
ranges are reported in Table 4.
The mean MPI values at 1, 2, and 3 years
after the start of prosthetic loading were
0.42 (SD0.5), 0.41 (SD0.6), and 0.35
(SD0.6), respectively. The mean MBI
values at 1, 2, and 3 years were 0.33(SD0.5), 0.29 (SD0.4), and 0.30
(SD0.4), respectively. The mean PD
values at 1, 2, and 3 years were 2.23mm
(SD0.7), 2.37mm (SD0.5), and
2.41mm (SD0.5), respectively.
None of the patients in group 2 dropped
out of the follow-up and no implants were
lost during the follow-up. Only two im-
plants presented peri-implant bone resorp-
tion values higher than the criteria
proposed by Albrektsson et al. Thus,
cumulative survival and success rates of
implants placed in group 2 at the end of the
follow-up period were 100% and 94.1%,
respectively (Table 7).
A case treated with the DO principle is
presented in Figs 814.
The comparison of results between the
two groups can be summarized as follows:
The difference in bone resorption before
implant placement between groups 1B and
2 was statistically significant (P < 0.01).
The difference at the time of abutment
connection, and 13 years after prosthetic
Fig.3 . Placement of three implants at an ideal prosthetic position with supracrestal exposure of implant
threads.
Fig.4 . The surgical field after bone grafting with autogenous bone chips and fixation of a titanium-reinforcede-PTFE membrane.
Fig. 5. At the time of abutment connection, implants appear completely embedded by new bone.
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loading between groups 1B and 2 was
statistically significant (P-values < 0.05,
< 0.05, < 0.01, < 0.05, respectively).
The difference in bone resorption be-
tween groups 1A and 1B between implant
placement and abutment connection and
1 year after prosthetic loading were statis-
tically significant (P-values0.01 and
0.05, respectively). No statistically signifi-
cant differences were found between groups
1A and 1B at 2 and 3 years after prostheticloading.
The difference in bone resorption be-
tween groups 1A and 2 at the time of
abutment connection and 13 years after
prosthetic loading was statistically signifi-
cant (P < 0.01 at all intervals).
The difference concerning the total bone
resorption at the end of the observation
period (the sum of measurements before
and after implant placement) between
group 1B and group 2 was statistically
significant (P < 0.01).No statistically significant differences
were found between the groups as far as
clinical parameters are concerned.
A significant difference was found be-
tween the groups as far as the success rates
of implants is concerned, whereas no
differences were found as far as survival
rates are concerned.
Discussion
Results from this study demonstrated that
vertically deficient edentulous ridges may
be corrected either by GBR or DO techni-
ques. Nevertheless, some considerations
have to be made.
The first issue refers to the complication
rate related to the two techniques. As far as
vertical GBR is concerned, membrane
exposure, which partially compromised
the final outcome of the bone regeneration,
occurred in three out of 11 patients
(27.3%). Instead, in the case of DO, two
cases only of lingual inclination of the
distracted segment occurred, but they were
easily corrected with an orthodontic appli-
ance without negative effects on the final
outcome of the prosthetic rehabilitation.
The second issue relates to the ability of
vertical GBR and DO in maintaining the
vertical bone gain over time. Two observa-
tion periods were considered: (a) before
implant placement (groups 1B and 2); and
(b) after implant placement (groups 1A, 1Band 2).
Groups 1B and 2 showed a significant
difference (P0.01) in bone resorption
before implant placement (1.35 mm, SD
0.9, range 0.53 mm and 0.37 mm, SD 0.4,
range 01.5 mm, respectively). Because of
the higher rate of initial bone loss in group
1B, it was necessary to place implants in a
more apical position, with suboptimal
prosthetic result from an esthetic and
functional point of view.
In group 1A, the mean peri-implant boneresorption values 13 years after prosthetic
loading were higher than those proposed by
Albrektsson et al. (1986). The mean bone
resorption during the follow-up period was
2.06mm (SD 0.9). Although 100% im-
plant survival rate was observed, the
success rate was significantly lower
(61.5%). In fact, five out of 13 presented
did not fulfill Albrektsson criteria. A bone
resorption of such magnitude (range: 1.5
4 mm) may be less than ideal, particularly
in case of implants placed in esthetic sites,
where the implant shoulder and threads
may become visible.
Fig.6 . Final prosthetic result.
Fig.7 . Radiographic control 1 year after the start of
prosthetic loading.
Table7. Group 2 (distraction osteogenesis) life table analysis showing cumulative survival and success rates of implants
Interval Implants at
start of
interval
Withdrawn
implants
Failing
implants
Implants under
risk at the end
of interval
Cumulative survival
rate (%)
Cumulative success
rate (%)
Placement to loading 34 0 0 34 100 100Loading to 1 year 34 0 0 34 100 100
12 years 34 6 0 28 100 100
23 years 28 17 2 11 100 94.1
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In group 1B patients, the mean peri-
implant bone resorption values 13 years
after prosthetic loading were apparently
within the limits proposed by Albrektsson
et al. (1986), but these values may be
misleading. Because implants were placed
in a staged approach, bone resorption of the
reconstructed area already occurred before
implant placement. Therefore, if we con-
sider the bone level obtained at the time of
the vertical GBR procedure as the baseline
of our measurements, the amount of bone
resorption at the end of the observation
period was the sum of bone resorption
before and after implant placement:
2.96mm (SD1.1). This value is signifi-
cantly higher than that obtained in the DO
group 1.93 (SD0.7).
This study demonstrated that higher
values of peri-implant bone resorption after
the removal of the membrane may occur as
compared to implants placed in native,
non-regenerated bone. This study also
demonstrated that success rates of implants
placed in areas treated with vertical GBR
are significantly lower than those obtained
in the case of implants placed in native,
non-reconstructed bone (Adell et al. 1990;
Chaytor et al 1991; Quirynen et al. 1992;
Lekholm et al. 1994; Bragger et al. 1996;
Lindquist et al. 1996; Buser et al. 1997;Arvidson et al. 1998; Behneke et al. 2000;
Weber et al. 2000; Leonhardt et al. 2002). In
these publications, bone resorption values
within the limits proposed by Albrektsson
et al. were reported, with cumulative
success ranging from 89% to 98.9% after
follow-up periods ranging from 3 to 15
years.
In group 2, the mean peri-implant bone
resorption values 13 years after the start of
prosthetic loading were within the limits
proposed by Albrektsson et al. (1986) andwere consistent with the results obtained in
case of implants placed in native bone
(Adell et al. 1990; Chaytor et al 1991;
Quirynen et al. 1992; Lekholm et al. 1994;
Bragger et al. 1996; Lindquist et al. 1996;
Buser et al. 1997; Arvidson et al. 1998;
Weber et al. 2000; Behneke et al. 2000;
Leonhardt et al. 2002). Only two implants
in one patient did not fulfill this parameter,
as reported in Table 6. It is worth noting
that in case of DO, the total bone resorption
at the end of the observation period (the
sum of bone resorption occurred before
implant placement and that occurred at
the end of the observation period was equal
to 1.93mm (SD0.7). This value is
significantly lower than that obtained after
GBR with staged implants (group 1B). This
seems to demonstrate that DO has a better
ability than GBR in maintaining the bone
gain obtained.
A survival rate of 100% and a success
rate of 94.1% seem to confirm that
implants placed in the neogenerated tissue
Fig.8 . Post-traumatic defect with loss of 314142 and vertical defect of the alveolar ridge.
Fig9. Panoramic radiograph showing the bony defect.
Fig.10. The surgical field after the osteotomy of the bony segment to be distracted and fixation of the
distraction device.
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by distraction osteogenesis can successfully
withstand the biomechanic demands of
implant loading, comparable to the results
obtained in case of implant placement
in native, residual alveolar bone (Albre-
ktsson et al. 1986; Adell et al. 1990; Laney
et al. 1991; Lekholm et al. 1994; Lindquist
et al. 1996; Buser et al. 1997; Arvidson
et al. 1998; Weber et al. 2000; Leonhardt
et al. 2002).
As far as clinical parameters are con-
cerned, no statistically significant differ-
ences were found in this study between the
two groups, and these values were consis-
tent with those reported in the literature(Mericske-Stern et al. 1994; Nishimura
et al. 1997; Levy et al. 1996; Behneke
et al. 2000; Leonhardt et al. 2002).
Conclusion
The following conclusions can be drawn
from the data of the present study and from
the analysis of the literature.
Vertical GBR appears to be a relatively
reliable reconstructive technique, but itneeds autogenous bone harvesting, which
increases operating times and postoperative
morbidity. In addition, early membrane
exposure may cause infection that may
compromise the final outcome of the
rehabilitation. This technique has been
mainly applied to limited defects with ver-
tical bone gains ranging from 2 to 7 mm, on
average (Simion et al. 1994; Jovanovic et al.
1995; Simion et al. 1998, 2001).
DO has proven to be a reliable technique,
as demonstrated by this study and other
publications (Hidding et al. 1998; Chiapas-
co et al. 2000, 2001; Consolo et al. 2000;
Robiony et al. 2002; Jensen et al. 2002;
Zaffe et al. 2002). The vertical bone gain
may reach more than 15 mm, it is obtained
in a more physiologic way, with no need of
bone transplantation, thus reducing morbid-
ity. Another advantage may include a
progressive elongation of the surrounding
soft tissues (neohistogenesis) with very
limited risk of wound dehiscence and bone
exposure. In this study as well as in previous
Fig.11. Radiographic control 2 days after the start of distraction.
Fig. 12. Control at the end of distraction: the correction of the vertical defect is clearly visible.
Fig. 13. Final prosthetic result.
Fig.14. Radiographic control 2 years after the start
of prosthetic loading.
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publications (Chiapasco et al. 2000, 2001),
the incidence of infection was 0%.
The results from this study seem to
indicate that DO, as compared to GBR,
may offer a better long-term prognosisas far
as bone gain maintenance and peri-implant
bone resorption after prosthetic loading are
concerned.
Survival rates of implants do not differ
between DO and GBR groups, whereas
success rates of implants differ significantly
(61.5% in group 1A; 75% in group 1B;
94.1% in group 2).
It must be stressed, however, that the
distraction device used in this study al-
lowed the correction of the vertical defect
only, whereas GBR permitted to correct
simultaneously a vertical and horizontal
defect. GBR techniques may be more
indicated for small defects and in case of a
combination of vertical and horizontaldefects. DO with intraoral extraosseousdis-
tractors of a single-tooth space may be in
fact more difficult to perform, due to the
limited space available for osteotomies and
to the dimensions of the distraction device.
Instead, in case of severe vertical defects
with the presence of a broad bony base, DO
may be more indicated because more
vertical gain may be achieved by DO than
GBR.
Resume
Le but de cette etude prospective a etede comparer
la regeneration osseuse guidee verticale (GBR) et
losteogenese de distraction verticale (DO) pour leur
potentiel a corriger les insuffisances verticales du
rebord alveolaire et leurs possibilites a maintenir
dans le temps ce gain osseux vertical obtenu avant et
apres le placement de limplant. Onze patients
(groupe 1) ont etetraites avec la GBR verticale avec
de los autogene et des membranes en teflon, tandis
que dix patients (Groupe 2) etaient traites avec la
DO. Dans le groupe 1, six patients ont recu des
implants au moment de la GBR (sous-groupe 1A)
tandis que cinq patients avaient des implants places
au moment de lenlevement de la membrane (sous-
groupe 1B). Dans le groupe 2, les implants ont ete
places au moment de lenlevement du systeme de
distraction. Au total, 25 implants etaient places dans
le groupe A et 34 dans le 2. Trois acinq mois apres le
placement des implants les patients ont ete traites
par des protheses dentaires portees sur implants. Les
parametres suivant ont eteevalues : a) la resorption
osseuse des rebords regeneres avant et apres le
placement de limplant, b) les parametres cliniques
paromplantaires un, deux, trois annees apres lamise
en charge, c) les taux de survie et de succes des
implants. Les valeurs de la resorption osseuse avant
et apres le placement des implants etaient significa-
tivement plus importantes dans le groupe 1. Les
resultats suggerent que les deux techniques peuvent
ameliorerle deficit durebordedenteresorbebienque
losteogenese de distraction semble etre plus pre-
visible along terme. Les taux de survie implantaire
ainsi que les parametres cliniques paromplantaires
ne differaient pas significativement entre les deux
groupes tandis que le taux de succes des implants
places dans le groupe 2 etait plus important que chez
les patients du groupe 1.
Zusammenfassung
Alveolare Distraktionsosteogenese gegenuber verti-
kaler gesteuerter Knochenregeneration fur die Kor-
rektur von vertikalen Defekten am zahnlosen
Kieferkamm: eine prospektive Studie an Menschen
uber 1 bis 3 Jahre
Das Ziel dieser prospektiven Studie war der Vergle-
ich zwischen der vertikalen gesteuerten Knochenre-
generation (GBR) und der vertikalen Distrak-
tionsosteogenese (DO) bei der Korrektur von
vertikalen Defekten an zahnlosen Kieferkammen.Zusatzlich wurde die Stabilitat des gewonnenen
Knochens uber die Zeit vor und nach Implantatplat-
zierung untersucht. Elf Patienten (Gruppe 1) wurden
mit vertikaler GBR mit autologem Knochen und e-
PTFE Membranen behandelt, wahrend bei 10
Patienten (Gruppe 2) die DO angewendet wurde.
In Gruppe 1 erhielten 6 Patienten zum Zeitpunkt
der GBR auch die Implantate (Untergruppe 1A),
wahrend bei 5 Patienten die Implantate nach der
Membranentfernung gesetzt wurden (Untergruppe
1B). In Gruppe 2 wurden die Implantate nach
Entfernung des Distraktionsapparats eingesetzt. In-
sgesamt wurden in Gruppe 1 25 Implantate und in
Gruppe 2 34 Implantate eingesetzt. Drei bis 5
Monate nach Implantation wurden die Patientenmit implantatgetragenen Prothesen rekonstruiert.
Die folgenden Parameter wurden ausgewertet: a)
Knochenresorption der regenerierten Kieferkamme
vor und nach Eingliederung der Implantate; b)
periimplantare klinische Parameter 1,2 und 3 Jahre
nach Beginn der prothetischen Belastung der Im-
plantate; c) Ueberlebens- und Erfolgsraten der Im-
plantate. Die Werte der Knochenresorption vor und
nach Implantatplatzierung waren in Gruppe 1
signifikant hoher.
Die Resultate lassen vermuten, dass beide Techni-
ken die Situation bei vertikal resorbierten zahnlosen
Kieferkammen verbessern konnen. Die Distraktion-
sosteogenese scheint bezuglich Langzeitprognosedes
vertikalen Knochengewinns besser abzuschneiden.
Die Ueberlebensraten der Implantate und die peri-
implantaren klinischen Parameter unterschieden
sich nicht signifikant zwischen den beiden
Gruppen. Aber die Erfolgsrate der Implantate war
bei Patienten der Gruppe 2 hoher als bei Patienten
der Gruppe 1.
Resumen
El proposito de este estudio prospectivo fue comparar
la regeneracion osea guiada vertical (GBR) y osteo-
genesis de distraccion vertical (DO) por su habilidad
en corregir crestas alveolares deficientes verticales y
su capacidad en mantener a lo largo del tiempo la
ganancia de hueso vertical obtenida antes y despues
de la colocacion del implante. Se trataron once
pacientes (grupo 1) por medio de GBR vertical con
hueso autogeno y membranas de e-PTFE, mientras
que 10 pacientes (grupo 2) se trataron por medio de
DO. En el grupo 1, seis pacientes recibieron
implantes en el momento de GBR (subgrupo 1A),
mientras que cinco pacientes recibieron los im-plantes en el momento de retirada de la membrana
(subgrupo 1B). En el grupo 2 los implantes se
colocaron en el momento de la retirada del disposi-
tivo de distraccion. Se colocaron un total de 25
implantes en el grupo 1, y 34 en los pacientes del
grupo 2. Tras 3 a 5 meses de la colocacion de los
implantes, los pacientes se rehabilitaron con protesis
dentales implantosoportadas. Se evaluaron los si-
guientes parametros: a) reabsorcion osea de las
crestas regeneradas antes y despues de la colocacion
de los implantes; b) parametros periodontales cln-
icos 1, 2, y 3 anos tras la carga protesica de los
implantes; c0 supervivencia e ndices de exito de los
implantes. Los valores de reabsorcion osea antes y
despues de la colocacion de los implantes fuesignificativamente mas alta en el grupo 1.
Los resultados sugieren que ambas tecnicas pueden
mejorar el deficit de la cresta edentulas vertical-
mente reabsorbidas, aunque la Osteogenesis de
distraccion parece ser mas predecible en cuanto al
pronostico a largo plazo de la ganancia de hueso se
refiere. Los ndices de supervivencia de implantes al
igual que los parametros clnicos no difirieron
significativamente entre los dos grupos, mientras
que el ndice de exito de los implantes colocados en
el grupo 2 fue mayor que aquel obtenido en los
pacientes del grupo 1.
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