This article evaluates the usage of distraction osteogenesis (DO) in the treatment of cleft alveoli. The procedure was carried out on eight alveolar clefts of five patients between the ages of 17 and 25 years. Three patients had bilateral alveolar clefts (BAC) and two patients had unilateral alveolar clefts (UAC). DO was carried out bilateral to the palatal segments for the BAC patients and unilateral to the lesser segment for the UAC patients. A custom-made tooth-borne distractor was used. The average amount of distraction was eight mm (range, 5–11.5 mm). The average amount of distal movement of the anchorage teeth was 0.8 mm (range, 0–2 mm). The average amount of inclination changes of the transport segments and anchorage teeth was 7.6° (range, 2–17.5°) and 3.3° (range, 0–9°), respectively. Two important problems were observed attributable to the method. First, the transport segment was docked in a more superior position at the end of distraction process. This undesirable movement also changed the inclination of the teeth in the transport segment and increased tooth tipping. Removing the device in the second week of the consolidation period and retracting the segment to its ideal position orthodontically solved these problems. Second, the bony defect on the nasal side of the alveolar cleft could not be completely closed. This method for repairing small or large alveolar clefts is a simple, cost-effective, and useful treatment option. However, repairing the alveolar cleft without grafts seems to be impossible when using a tooth-borne device.

Secondary bone grafting of the alveolar cleft at the stage of the transitional dentition, in conjunction with orthodontic treatment, has become a well-accepted treatment modality. Benefits of secondary grafting reported in the literature include increased bone support for teeth adjacent to the cleft site, presence of a bony matrix for the eruption of the teeth in the line of the cleft site, bony continuity in the maxillary arch and creation of a satisfactory alveolar bone contour, support of the arch width and prevention of maxillary arch collapse, stabilization of maxillary segments, elimination of oronasal fistulas, improved facial symmetry, alar base support, and nasolabial contour and improved status of oral hygiene by separating the nasal cavity from the oral cavity.1–16 

Unusually wide alveolar clefts are often associated with a large palatal fistula and their management is rather difficult. Segmental osteotomies have been the choice of treatment for closing wide clefts.17 Dental prostheses with or without dental implants are sometimes considered a treatment alternative.18 

Distraction osteogenesis (DO), which has become quite popular in oral and maxillofacial surgery in recent years, has begun to be used for narrowing large alveolar clefts before grafting. This method is based on distracting a dento-osseous segment created posterior to the cleft site and narrowing the large alveolar defect with mesial movement of this segment. New alveolar bone and soft tissue can be generated by this technique. Thus, the alveolar cleft can be more easily repaired with a bone graft, and this makes an ideal soft tissue closure possible using newly generated attached gingiva.19,20 In this article, we demonstrate a useful method for repairing alveolar clefts by DO.

The procedure was carried out on eight alveolar clefts of five nonsyndromic cleft lip and palate patients between the ages of 17 and 25 years (mean 21.4). These patients had received lip and soft palate repairs in other different centers; however, they had not received any alveolar correction until they were referred to our department. Three patients had bilateral alveolar clefts (BAC) and two patients had unilateral alveolar clefts (UAC) (Table 1). Four of the patients were under orthodontic treatment for over three years, whereas one did not have orthodontic treatment before surgery.

TABLE 1.

Distribution of Patients and Treatment Outcomes

Distribution of Patients and Treatment Outcomes
Distribution of Patients and Treatment Outcomes

One of the patients had a horizontally impacted canine tooth adjacent to the cleft that was extracted during surgery. None of the other patients had unerupted teeth near the cleft areas. DO was carried out bilateral to the palatal segments for the BAC patients and unilateral to the lesser segment for the other patients (Figures 1 through 4). The periodontal condition of teeth to be distracted or used as anchorage was determined to be acceptable clinically and radiologically.

FIGURE 1.

(A) View of the dentition before orthodontic treatment. (B) View of the cleft after palatal expansion and teeth alignment. (C) Palatal view of the dentition after palatal expansion and teeth alignment. (D) Palatal view of the dentition at the end of the distraction process. (E) Moving the transport segment to its ideal location orthodontically. Note chin ligature planned to help this application. (F) View of the dentition through the end of orthodontic treatment. (G) Palatal view of the dentition after rapid orthodontic tooth movement through the end of orthodontic treatment

FIGURE 1.

(A) View of the dentition before orthodontic treatment. (B) View of the cleft after palatal expansion and teeth alignment. (C) Palatal view of the dentition after palatal expansion and teeth alignment. (D) Palatal view of the dentition at the end of the distraction process. (E) Moving the transport segment to its ideal location orthodontically. Note chin ligature planned to help this application. (F) View of the dentition through the end of orthodontic treatment. (G) Palatal view of the dentition after rapid orthodontic tooth movement through the end of orthodontic treatment

Close modal

First molar and second premolars were used in two patients for anchorage. In the other patients, only first molar teeth were used. In four patients, the transported dento-osseous segment contained two teeth, and in one patient, there was only one tooth in the transport segment. The BAC patients had major alveolar defects that were difficult to treat by conventional grafting. Although autogenous grafting into the unilateral cleft patients could repair the site defects, we planned to accelerate the orthodontic treatment, and the procedures were completed with gingivoperiosteotoplasty. Palatal expansion was performed in all patients before DO. In the oldest patient, palatal expansion was aided surgically.

A custom made tooth-borne distractor was fabricated from a hyrax screw (Lewa Dental, 1114-22) and soldered to the orthodontic bands. As soon as the orthodontic bands were applied to the tooth or teeth that would be used for anchorage and to the tooth or teeth on the transport segment, an impression was taken and a model was obtained. The lower arm of the hyrax screw was bent on the cast according to the desired distraction vector and then soldered to the bands. Adaptation of the device was tested clinically before surgery.

The surgical procedure was performed under local anesthesia. After reflecting the mucoperiosteal flap from the vestibular side, a transport dento-osseous segment was created. A horizontal osteotomy line passing approximately 4–5 mm above the dental root apices and a vertical osteotomy line in the interdental region was outlined monocortically with small burs and saws. A palatal cortical osteotomy was then completed using fine osteotomes. Care was taken to protect the dental structures. The osteotomized segment was mobilized by hand and the mucoperiosteal flap closed primarily. The distraction device was attached to the teeth with glass ionomer cement immediately after surgery. Antibiotics, analgesics, and mouthwash were prescribed.

After a three-day latency period, distraction was initiated. The device was activated twice a day to achieve 0.5 mm per day advancement. The activation process was continued until both sides of the cleft came into contact. The distractor was left in place for one week after the activation period. Then it was removed, and the transport segment was fixed orthodontically. On the same day, the downward movement of the transported segment to its ideal location was begun orthodontically. This process took approximately 10 days. After the segment reached its desired position, it was immobilized orthodontically and left in place again for one month to achieve complete consolidation. In one UAC patient, the posterior teeth were rapidly moved into newly generated bone to close the diastema after the transported dento-osseous segment reached an ideal location.

The amount of distraction, distal movements of the anchorage teeth, and inclinational changes of teeth where the distractor had been placed were measured after completing the distraction period. Dimensional measurements were calculated by comparing the occlusal relationships of pre- and postdistraction models and using the lower first molar tooth as a reference. Angular measurements were done on pre- and postdistraction panoramic radiographs using the method described by Ursi et al.21 If a transport segment contained more than one tooth, only the mesially located teeth were used for evaluation. When measuring the changes of anchorage teeth, only the first molar teeth were evaluated.

The comparison of the first and second tracings of the patient records yielded the following correlation coefficient values: inclination of anchorage tooth (R) 0.983, inclination of anchorage tooth (L) 0.997, inclination of transported tooth (R) 0.996, and inclination of transported tooth (L) 0.995. There was a high correlation between different measurements of the records, and the measurements were highly repeatable.

The procedure and the postoperative period were tolerated well by all patients. A mean of eight mm of distraction (range, 5–11.5 mm) was observed. A mean of 0.8 mm of distal movements of anchorage teeth (range 0–2 mm) was observed. Mean inclination change of the transport segments and anchorage teeth was 7.6° (range, 2–17.5°) and 3.3° (range, 0–9°), respectively (Table 1). At the end of the distraction period, the transport segments were positioned 2–3 mm superior to the occlusal plane, although the direction of distraction was initially parallel to the occlusion plane.

No adverse tissue responses were seen during the distraction period except for small hyperemic areas at the top of the alveolar crestal mucosa. This was completely resolved at the end of the consolidation period. The transported dento-osseous segments were stable after the consolidation period. The alveolar clefts were completely closed at the top of the alveolar crest and approximated on the nasal side. The radiographic evaluation showed residual triangular bony deficits. The base of this triangle was at the nasal cavity basis and its tip was at the alveolar crest. The dental movements were not more than the bony tissues' movements, and the anchorage loss was minimal. The oronasal passage was significantly reduced in the BAC patients. This problem was completely resolved in the unilateral cleft patients whose treatment was combined with gingivoperiosteoplasty. Epistaxis was seen in one patient on the fourth day of the distraction period. Nasal packing was sufficient to treat this complication. In another patient, the device broke at the solder joint on the third day of the distraction period. The device was atraumatically removed, repaired, and replaced.

Bone grafting has become a common procedure in the treatment of cleft lip and palate patients. The main difference in the treatment protocol of various rehabilitation centers is the timing of bone grafting. According to its time of occurrence, the bone graft may be considered primary (in early childhood), secondary (during the mixed dentition), or tertiary (in the permanent dentition). Primary grafting of a cleft alveolus has been abandoned by most rehabilitation centers where it had been formerly performed because of the possibility of impaired maxillary growth.22 Occasionally, late grafts cause progressive root resorption of the teeth adjacent to cleft side, especially the canines.23,24 Today, the most widely accepted procedure is secondary bone grafting.25 

DO was introduced by orthopedists for lengthening long bones.26 In the maxillofacial region, the first clinical uses were correcting mandibular deficiencies and advancement of maxilla and midface.27,28 In the dento-alveolar region, DO was used initially to reconstruct vertical alveolar defects and later for various indications such as moving ankylosed central incisors, advancing of the anterior maxilla, accelerating orthodontic treatment, and resolving dental crowding.28–32 It was shown, both experimentally and clinically, that dental movements into new bone generated by DO was possible.19,33 

The method used in this study is based on the transport DO concept. This technique, which was originally designed to repair the defects in long bones, has also been used to correct mandibular defects and to reconstruct the temporomandibular joint.34–37 In these cases, the deficiency is reconstructed by distracting the transport disk under soft tissues. We used this procedure in UAC patients with double-layer soft tissue closure according to conventional techniques and moved the transport disk through the soft tissues. In BAC patients, however, soft tissue closure was postponed until after DO because the soft tissues were insufficient to obtain a primary closure in these patients. Although it was possible to make a closure with flaps prepared from the cheek or tongue, these tissues were not appropriate for use in the alveolar region.

Orthodontic tooth alignment and expansion of any maxillary collapse should definitely be completed before treating alveolar clefts. This procedure enlarges the cleft and the palatal fistula. Sometimes this newly enlarged defect is so large that it makes it impossible to perform a conventional graft procedure. Another treatment alternative is to create segmental osteotomies and to close the segments. The surrounding soft tissues, however, may not allow big movements and may compromise tissue nutrition. DO has been recently used in these rare cases.19,20 A transport segment, prepared from the posterior region of the cleft, can be advanced anteriorly, and the cleft is narrowed. Thus, the amount of bone and soft tissues in lesser segment can be increased, adequate soft tissue provided, and the required graft volume reduced in size.

It has been experimentally and clinically shown that tooth-borne devices could be used in DO.30,38 Although some experiments showed that tooth-borne appliances caused more dental movements than bony movement, we did not observe much dental movement in this study.38 In these cases of more dental movement, osteotomies might have been incomplete, leading to insufficient mobilization of the segment to be distracted.

We encountered two important problems attributable to the distractor we used. First, the transport segment was docked in a more superior position at the end of the distraction process. This undesirable movement also changed the inclination of the teeth in the transport segment and increased tooth tipping. Removing the device in the second week of the consolidation period and orthodontically retracting the segment to its ideal position solved these problems. This became possible because of immature bone formation in distraction area and did not affect final healing. Second, the bony defect on the nasal side of the alveolar cleft could not be completely closed. In some cases, we placed a wire ligature on the superior side of the transport disk close to the medial aspect and exposed it into oral cavity. This wire was used to retract the superiorly positioned segment to its ideal location and to close the residual defect existing in the basal region at the end of distraction. However, it was not possible to make a perfect closure. A bone-borne distractor placed above the transport segment may solve this problem, and clefts may be repaired without grafting. The literature contains a description of a distractor located in such a position in an experimental study, but no detailed clinical results are given.39 

The inclinational changes of the anchorage teeth and the amount of distal movement were not significant. Thus, it was shown that first molar tooth could give adequate support for transporting a segment that contains one or two teeth. When transporting a larger segment, it may be necessary to include bony support in addition to the molar tooth anchorage.

No relapse was observed in the 13.2 months (range, 6–24 months) of follow-up. Although there were residual defects in the nasal base in the UACs, we did not plan to perform a grafting procedure because the oronasal passage was entirely closed. All patients are still in orthodontic treatment. Iliac bone grafting will be performed for premaxillary stabilization in BAC patients after orthodontic preparation.

In one patient who underwent rapid orthodontic tooth movement through the new generated bone, orthodontic closure of the diastema created with distraction was completed in three months, and this in turn will decrease the treatment period dramatically. Other patients will receive fixed prostheses for rehabilitation of distraction site diastemata after completion of orthodontic treatment.

Liou et al19 used a daily-activated device as used in tooth-borne and conventional distractors. Yen et al20 treated a large unilateral cleft using a tooth- and bone-borne device made from conventional orthodontic devices and applied a continuous eight oz force. These authors stated that they provided a three-dimensional control of movement by preparing an arch-shaped device or bending the device during the distraction period. The distractor we used did not have such a mechanism, but this did not affect the treatment outcomes. In the early consolidation period, the distracted segment moved easily to a desired location.

The advantages of this technique are increased arch dimensions at the posterior side of the cleft, resolution of dental crowding without extractions, possibility of fast dental movements in the newly generated alveolar bone, possibility of completion of orthodontic treatment in a shorter time, and production of a neogenerated alveolar bone that allows dental implantation. Because the soft palate is not advanced anteriorly, velopharyngeal incompetence does not increase.19,20 

This method for repairing small or large alveolar clefts is a simple, cost-effective, and useful treatment option. However, repairing the alveolar cleft without grafts seems to be impossible when using tooth-borne distractors. Developing more efficient tools can make the treatment possible without bone grafting.

FIGURE 2.

(A) Radiographic view of the dentition before distraction osteogenesis. (B) Radiographic view, at the end of the distraction. Note the superiorly positioned transport segment. (C) Radiographic view after correction of tilted distraction segment and rapid orthodontic tooth movement

FIGURE 2.

(A) Radiographic view of the dentition before distraction osteogenesis. (B) Radiographic view, at the end of the distraction. Note the superiorly positioned transport segment. (C) Radiographic view after correction of tilted distraction segment and rapid orthodontic tooth movement

Close modal
FIGURE 3.

(A) Frontal view of the dentition before orthodontic treatment. (B) Palatal view of the dentition before orthodontic treatment. (C) Occlusal view of the maxilla after expansion and tooth alignment. Please note that the lateral incisors are extracted. Primary treatment plan included these extractions because distraction was not planned at that time. (D–E) Lateral views of the dentition before distraction osteogenesis. (F) Palatal view, at the end of the distraction process.

FIGURE 3.

(A) Frontal view of the dentition before orthodontic treatment. (B) Palatal view of the dentition before orthodontic treatment. (C) Occlusal view of the maxilla after expansion and tooth alignment. Please note that the lateral incisors are extracted. Primary treatment plan included these extractions because distraction was not planned at that time. (D–E) Lateral views of the dentition before distraction osteogenesis. (F) Palatal view, at the end of the distraction process.

Close modal
FIGURE 4.

(A) Radiographic view of the dentition before distraction osteogenesis. (B) Radiological view, at the end of the distraction. (C) Radiological view after transport segments moved to its ideal location orthodontically.

FIGURE 4.

(A) Radiographic view of the dentition before distraction osteogenesis. (B) Radiological view, at the end of the distraction. (C) Radiological view after transport segments moved to its ideal location orthodontically.

Close modal
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Author notes

dCorresponding author: Dogan Dolanmaz, DDS, PhD, Selcuk Universitesi, Dis Hekimligi Fakultesi, ADCH. ve Cerrahisi AD 42079 Kampus, Konya, Turkey ([email protected])