A l v e o l a r Di s t r a c t i o n

Elçin Esenlik, DDS, PhDa,*, Evellyn M. DeMitchell-Rodriguez, BSb

KEYWORDS
 Cleft lip and palate  Alveolar distraction  Closing the cleft gap  Alveolar grafting

KEY POINTS
 Alveolar distraction is used for lengthening, widening, or augmenting the alveolus in patients with a
wide or complex alveolar cleft.
 Alveolar distraction can approximate the alveolar segments to reduce the size of the bony defi-
ciency and the fistula.
 A smaller alveolar cleft and smaller fistula leads to more predictable outcomes to bony reconstruc-
tion.

INTRODUCTION been reported in the literature, there are limitations

of these grafting procedures. For example, the
Congenital or acquired alveolar bone defects often bone grafted area may resorb due to poor stabili-
are encountered in the dental practice. The former zation, limited bone contact, soft tissue tension,
generally are associated with craniofacial anoma- and vascularization problems due to the large vol-
lies, such as cleft lip and palate. These bony defi- ume of the graft material.1,3 As an alternative treat-
ciencies have stereotypical characteristics, such ment to grafting, alveolar distraction osteogenesis
as maxillary halves with deficient bone, lack of (ADO) has been suggested to increase bone vol-
nasal floor support, and a hypoplastic maxilla. Ac- ume in patients with and without cleft. The com-
quired alveolar defects may be caused by trauma, mon indications for the general population in
periodontal diseases, tooth extraction, congenital dental practice and specific indications for the
tooth agenesis, and tumor resection and can pre- cleft lip and palate population are summarized
sent in a more variable pattern. Alveolar defects from an orthodontist’s perspective.
can be primarily in the horizontal dimension and
often are associated with vertical resorptions,
which require bone augmentation.1 In modern GOALS OF ALVEOLAR DISTRACTION
dentistry, restoration of the missing teeth and atro-
ADO has become increasingly popular in ortho-
phic alveolus in patients with or without cleft has
dontics after rapid canine retraction with the
shifted from large obturators and bulky removable
distraction procedure was introduced by Liou
prostheses to providing a bony platform for
and colleagues4 for shortening the treatment dura-
implant restorations and an esthetic soft tissue lin-
tion. Several types of distractors and distraction
ing of the smile.
types have been introduced for different purposes,
Several augmentation methods have been
including lengthening, widening, and augmenting
developed for increasing the volume of alveolar
the alveolus. Indications and conditions include
bone for patients without a cleft. Autologous or
allogenic grafting is a common technique used to  Rapid canine distalization4
establish a bony platform for dental rehabilitation  Atrophic alveolus due to congenital missing or
in patients with atrophic alveolus of various etiol- lost teeth and edentulous jaws5,6
plasticsurgery.theclinics.com

ogies.2 Although successfully treated cases have  Management of ankylosed teeth7

The authors have no conflict of commercial or financial conflicts of interest and any funding sources.
a
Faculty of Dentistry, Department of Orthodontics, Akdeniz University, Dumlupinar cad, Konyaaltı, Antalya
07058, Turkey; b Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, 550 1st Avenue, New
York, NY 10016, USA
* Corresponding author.
E-mail address: elcinesenlik@gmail.com

Clin Plastic Surg 48 (2021) 419–429

https://doi.org/10.1016/j.cps.2021.02.004
0094-1298/21/Ó 2021 Elsevier Inc. All rights reserved.
420 Esenlik & DeMitchell-Rodriguez

 Alveolar/partial jaw deficiencies after tumor HORIZONTAL ALVEOLAR DISTRACTION

resections or trauma6
 Approximation of cleft segments in patients Horizontal alveolar distraction (HAD) is used for
with cleft lip and palate8 expanding the atrophic alveolar crest. This
widening has been performed conventionally us-
The goals of ADO include ing different bone grafting procedures. Similar to
conventional vertical augmentation techniques,
 To improve the shape of the alveolar arch in 3 these routine surgeries have resulted in severe
dimensions (3-D) bone resorption.11 Therefore, alveolar distraction
 To expand the alveolar bone volume for sub- technique has been suggested by dental practi-
sequent orthodontic treatment tioners who experienced bone resorption and dif-
 To restore the vertical height of the alveolus ficulty inserting osseointegrated implants.
before dental rehabilitation (implant place- Osseointegrated implants cannot be inserted suc-
ment and prosthetic restoration) cessfully in patients exhibiting an alveolar ridge
Multiple alveolar distraction procedures have less than 5 mm12 and the narrow alveolus hinders
been described to treat bony and soft tissue defi- the orthodontic tooth movement due to the insuffi-
ciencies of the jaws. These procedures are sum- cient bone coverage of the teeth. HAD has been
marized as vertical, horizontal, and sagittal used since 2004 and has been shown superior to
distraction techniques as well as alveolar distrac- conventional grafting due to less infection risk
tion in patients with a cleft. A 3-D understanding and minimal resorption postoperatively.11
of the bony and soft tissue deficiencies associated Both VAD and HAD are preferred in select cases
with the defect is critical to planning an effective due to the decreased overall treatment time
treatment plan. compared with conventional staged bone grafting
techniques. Sufficient bone generation by the
distraction allows for stable implant restoration
VERTICAL ALVEOLAR DISTRACTION without the need for graft surgery. The relapse or
Vertical alveolar distraction (VAD) is used to treat resorption of the generated bone has been found
local alveolar atrophy caused by traumatic tooth to be limited.13 Long-term data and prospective
loss, previous failed grafting, or an ankylosed randomized clinical trial assessment, however,
tooth.1,7 VAD was first reported as a case series are lacking.
by Chin and Toth5 in 1996, in which different
distraction methods were described. Included in SAGITTAL ALVEOLAR DISTRACTION
this study was a patient who had suffered a trau- ADO in the sagittal plane has been commonly
matic injury and required bone and mucosa preferred in patients with cleft lip or palate for
augmentation in the anterior mandible. The inves- reducing the cleft gap and in patients who have
tigators distracted the atrophic edentulous bone undergone partial resection of the maxilla or
vertically, which allowed them to insert implants mandible due to a tumor resection.6 Patients
for dental rehabilitation. Now, after 2 decades of with cleft lip or palate may have deficiencies in
use, the method is considered an excellent solu- any of the 3 planes that require vertical, horizontal,
tion for bone and soft tissue regeneration in areas or sagittal distraction, and the geometry of bony
with significant bone atrophy. deficiency must be correctly diagnosed in 3-D in
A systematic review of VAD concluded that sur- order to formulate an effective treatment plan.
vival rate of the dental implants in cases utilizing
vertical distraction was similar to those without
ALVEOLAR DISTRACTION FOR PATIENTS
any augmentation technique.6 Generated bone
WITH CLEFT
height can be up to 15 mm in certain cases.1
Nature of the Problem
Although VAD has shown to be a useful tool for
bone and soft tissue augmentation, overcorrec- In patients with a cleft, alveolar defects requiring
tion at a 10% to 20% rate is recommended, VAD or HAD present unique challenges because
because a degree of relapse may occur during an oral cleft commonly is associated with oronasal
consolidation period.9 Additionally, although this communication and a soft tissue deficiency. There
technique has been reported in more than 300 is a wide variation in the extent of the cleft defor-
cases in the literature, long-term data are lacking. mity from mild to severe and many alveolar defects
Of the available studies that discuss long-term re- easily can be managed using traditional surgical
sults, the alveolar marginal bone demonstrates and orthodontic techniques. Complex alveolar de-
approximately 15% to 20% resorption at 5-year fects associated with a large fistula, wide bony
follow-up.10 gap, rudimentary premaxilla, or a malformed cleft
 Alveolar Distraction 421

segment may benefit from more specialized inter- done at the time a bone graft is done, which pro-
ventions.3 Different techniques have been sug- vides stability and maxillary continuity.18 In cases
gested for the reconstruction of these defects, of a large fistula located at the hard palate near
such as buccal or tongue flaps as well as obtura- the alveolus, the fistula can be reduced by the
tors to cover the remaining cleft defect.14,15 distraction, resulting in a smaller defect that can
Although secondary alveolar bone grafting is the be closed more easily. Liou and Chen8 reported
gold standard for reconstruction n of the maxillary their 21 cases in which they performed alveolar
bony cleft, the presence of a hypoplastic maxilla, distraction procedure for approximation of the
significant vertical discrepancy of the alveolar seg- cleft segments. They obtained an average of 12-
ments and minimum contact surface between the mm distraction with a range of 10 mm to 20 mm,
cleft segments, malposition of the segments in and their 5-year follow-up showed stable results.8
more than 1 dimension, and soft tissue deficiency Another advantage of alveolar distraction is
are considered risk factors for grafting surgery. providing vertical alignment of the cleft segments
Additionally, cases of flared or deviated hypoplas- when needed. This can be achieved by either per-
tic premaxilla with large cleft gaps also pose chal- forming VAD following sagittal transposition as re-
lenges for traditional grafting techniques due to ported by Rachmiel and colleagues19 or by
blood supply and deficiency of the soft and hard remodeling the soft callus after the distraction
tissues and often lead to grafting failures or unideal period. Because VAD can align the alveolar seg-
reconstructions. Moreover, previous surgeries and ments properly in the vertical plane, bone graft
failed grafting procedures leave more scar and survival is improved through the formation of bet-
resorptive bone margins behind, making future ter contact surface between the alveolar
procedures more challenging for clinicians.8 In segments.
such cases, ADO has been suggested as an alter- ADO also expands the mucoperiosteal lining
native method to increase the success rate of the associated with the transported bone, decreasing
grafting procedure and increase the bone volume. soft tissue tension at the time of bone graft, and
The orthodontic treatment of a patient with a improving graft take.18 The restoration of a
cleft also is challenged by additional variables single-piece maxilla facilitates future orthognathic
not related directly to diagnosis of cleft lip and pal- surgery. Furthermore, sagittal transposition of the
ate. For example, the Decayed, Missing, and Filled lesser segment medially delivers osseous tissue
Teeth (DMFT) index rate has been reported to be to the deficient nasolabial area, providing better
significantly higher than in noncleft controls, structural support of the soft tissues as well as
regardless of the sample origin. Furthermore, an augmented bony foundation for orthodontic
tooth anomalies, malpositions, and malformed tooth movement, resulting in a more pleasant
roots frequently are observed in these patients.16 prosthetic restoration. Finally, improvement of
These anomalies and alveolar bone deficiencies the maxillary arch can be facilitated by this
can create challenges to orthodontic treatment, approach (from V shape to ovoid arch form) as
because the use of routine orthodontic anchorage well, if there is a lack of bone in the anterior re-
systems may not be feasible. In these cases, alve- gion.20 Even though providing a curvilinear arch
olar distraction is recommended to obtain better form is not easily established, case-specific de-
surgical and orthodontic results. vices and postdistraction orthodontics are utilized
to obtain a good platform. Although ADO has been
shown beneficial, randomized controlled trial
Clinical Relevance
studies that compare success rates of traditional
ADO has been implemented in select patients with alveolar grafting to ADO methods currently are
a cleft due to the ability to decrease the size of the lacking.
alveolar gap, which can increase the success rate
of subsequent bone grafting.8 Liou and Chen8
Presurgical Orthodontic Preparation
suggested the use of alveolar distraction when
the cleft gap is wider than a canine tooth. Because Presurgical orthodontics include aligning the teeth
large cleft gaps and the presence of large oronasal to establish a robust anchorage, creating a suffi-
fistulas are particularly challenging to repair, cient interdental space for the osteotomy site
commonly requiring repetitive surgeries,14 ADO and making a case-specific appliance for the
may be an important treatment options in this distraction. Maxillary teeth are aligned first, as
challenging subset of patients. There is no much as the alveolus remodeling capacity allows.
consensus on the treatment of oronasal fistulas Next, a stainless steel rectangular arch wire should
located in the alveolar region in the literature.17 It be engaged to the brackets. This arch should be
was stated that the closure of the fistulas can be as large as possible to provide stability for future
422 Esenlik & DeMitchell-Rodriguez

alveolar transposition. This arch wire also can be be 0.5 mm or 1 mm per day,21 with a frequency up
used to expand the maxillary arch just after the to twice a day. The distraction procedure is
activation period in the event that the transport continued until the transport segment reaches
segment collapses palatally. A transpalatal arch the targeted area by closing the alveolar gap in
bar made of stainless steel can be used for guiding cleft population or planned final tissue expansion
the transport segment direction and to prevent in the noncleft population. Caution should be
medial and palatal collapse.9,20,21 Erverdi and col- used, because the amount of distractor activation
leagues20 describe using metal crowns if the num- tends to be more than the estimated amount, and
ber of the teeth are not sufficient for the the actual increase in width might not be the same
anchorage. as the amount of activation.24 Therefore, an
In certain complex cases, there may be multiple amount of activation exceeding the size of the
occlusal planes due to differing vertical positions alveolar cleft should be planned for, and the dis-
of the alveolar segments. In these cases, the use tractor device should have enough capacity to
of segmental arches is recommended in order to fulfill this increased need.
avoid excessive tooth movement; thus, aligning The distracted segment should be translated
the teeth is done separately for each segment. without inclination toward the greater segment
Following the leveling, interdental space is (or premaxilla) to maximize surface apposition be-
enlarged orthodontically at the planned osteotomy tween the alveolar segments and to minimize
site for avoiding any periodontal injuries and root displacement between the segments. In certain
damage. It has been suggested that a 3-mm gap cases, early contact can occur due to bone irreg-
should be released orthodontically between teeth ularities or soft tissue prominences along the
and the osteotomy line.21 If the incisor tooth adja- advancing surface. Under these circumstances,
cent to the cleft is rotated or extremely retruded the transported segment may be tilted during acti-
and enough bone coverage of the teeth on the cleft vation to optimize reduction of the alveolar cleft.
side exists, it can be derotated orthodontically to Therefore, the final position of the alveolar
create an accessible surgical area. segment should be determined by: best reduction
Periodontal health is of great importance to of the maxillary cleft an occlusion. If the alveolar
ensure the success of soft tissue distraction. As gap is larger than 2 mm, a bone grafting procedure
in traditional grafting procedures, oral hygiene is suggested and if it is less than 2 mm, then gingi-
should be optimized preoperatively and postoper- voperiosteoplasty may be considered.8 Gingivo-
atively to avoid bone resorption. Another important periosteoplasty is more efficacious when
aspect to consider is elimination of possible pri- performed at the time of infancy. An important fac-
mary contacts of the transporting segment tor during the activation period is the soft tissue
because of the overerupted or inclined teeth at expansion of the mucosal lining during the distrac-
the maxillary or mandibular arches on the planned tion process. Otherwise, soft tissue dehiscence
route. To avoid this risk, a removable acrylic plate can occur, resulting in an open wound that could
can be made for the mandibular arch to prevent risk the success procedure.
premature contact of the tooth apices during acti- When activation is completed, the distractor is
vation and to establish a smooth platform for the converted to a passive mode as a consolidation
transportation. device. After a consolidation between 3 months
and 4 months,21,25 alveolar bone graft is per-
DISTRACTION PROCEDURE formed and postdistraction orthodontics is
completed to move the teeth distally into the
The age of 9 years to 10 years is the suggested generated bone.
age for alveolar distraction for cleft approximation
in order to graft the area before canine eruption.8 TYPES OF DISTRACTORS
In cases that require tertiary bone graft (after
canine eruption), ADO can be performed at any The choice of distractor (custom-made or manu-
time prior to the bone graft procedure.22 Alveolar factured) depends on the clinical circumstances,
distraction involves osteotomy, latent phase, including the type of bone defect, dentition, and
transport (active distraction), and consolidation experience of the clinicians. Alveolar distractors
periods similar to distraction in other craniofacial can be classified as tooth-borne, bone-borne, or
areas. hybrid based on the anchorage type. Liou and
The latency period in alveolar distraction should Chen,8 who reported the first alveolar distraction
be between 4 days to 7 days.20,21,23 The length of for approximating the cleft segments, used
this period is determined according to the extent tooth-borne distractors, which were attached to
of soft tissue healing. The rate of activation should the dentition only. Erverdi and colleagues20 also
 Alveolar Distraction 423

designed a tooth-borne distractor that they twice-daily activation for a period of 3 weeks.
referred to as “archwise distraction” for the cleft The same distractor was used during the consoli-
approximation.21 Clinicians who use tooth-borne dation period of 4.5 months (Fig. 1G, H). Alveolar
devices report that arch wire guidance can trans- bone graft was performed after consolidation
port the alveolar segment to achieve an anatomic was completed. A gingival recession occurred at
curvilinear movement along the dental the maxillary first premolar (Fig. 1I). Postoperative
arch.19,20,23 In contrast, Mitsugi and colleagues22 panoramic radiograph showed narrowing of the
prefer bone-borne devices for sagittal distraction alveolar cleft and new bone at the cleft site
because tooth-borne devices impose a burden compared with the presurgical panoramic radio-
on the teeth and caused an unstable fixation, graph (Fig. 1J, K). Orthognathic surgery was
which is unfavorable for controlled bone transport. planned for the maxillomandibular discrepancy.
They reported 22 cleft cases that underwent ADO
with fabricated bone-borne distractors and re- Case 2
ported a degree of curvilinear transport was A 14-year-old boy with a right unilateral complete
achieved through guidance of the arch wire.22 cleft lip and palate presents with a congenitally ab-
Rachmiel and colleagues18 also used bone- sent maxillary lateral tooth, a large alveolar cleft,
borne distractors for both sagittal and vertical and associated fistula (Fig. 2A, B). The patient
distraction in a patient with severe cleft defect. had undergone a secondary alveolar bone grafting
Rapid palatal expansion screws (hyrax-type) previously but this procedure failed. Due to the
commonly are used for custom-made devices, large bony defect, alveolar distraction of the lesser
which can reduce cost of care. This screw can be segment was planned before the second grafting
inserted parallel to the palatal surface or along the surgery. A Liou Cleft Distractor (KLS Martin, Jack-
vestibular side of the teeth. Various designs using sonville, Florida) was used to transport the alveolar
these expansion screws have been introduced ac- segment (Fig. 2C–E). After 22 days of activation, at
cording to the anchorage site and the planned route a rate of 0.5 mm/d, and a 5-month consolidation
of the transport segment.19,23 Zemann and col- period (Fig. 2F, G), the patient underwent second-
leagues21 reported 6 cases that underwent alveolar ary alveolar bone graft. New bone was generated
distraction and achieved curvilinear transport of the at the alveolar cleft 9 months after the surgery
segment using an expansion screw at the buccal (Fig. 2H). At 2-year follow-up of the distraction,
side and a transpalatal bar. Other clinicians prefer panoramic radiograph showed stable results
to combine tooth-borne devices and temporary (Fig. 2I).
anchorage devices (TADs).21 Both expansion screw
devices and fabricated intraoral distractors should Case 3
be oriented properly to avoid any protrusions
through the buccal side or the palatal side, which A 19-year-old man with bilateral cleft lip and palate
can cause tongue irritation. underwent a previous and unsuccessful alveolar
bone graft. He presented with a diminutive and
CASE PRESENTATIONS edentulous premaxilla, which was deviated to the
right side and associated with a large left-sided
The following cases reports are successful appli- oronasal fistula (Fig. 3A). A combined of tooth
cations of ADO using bone-borne or a combina- and bone-borne distractor was created to
tion of tooth-borne and bone-borne devices in decrease the size of the alveolar cleft on the left
patients with a cleft. side (Fig. 3B–D). After an activation period of
approximately 2 weeks and completion of consol-
Case 1 idation, alveolar bone graft was performed
An 18-year-old man with unilateral cleft lip and pal- (Fig. 3E, F). Five-year follow-up examination
ate presents with a large oronasal fistula and an showed stable results (Fig. 3G).
alveolar cleft on the left side (Fig. 1A–C). Alveolar
Case 4
distraction was planned to reduce the alveolar
cleft following presurgical orthodontics. After A 21-year-old man with unilateral cleft lip and palate
inserting brackets and arch wires, maxillary teeth presents with a large alveolar cleft and associated
were aligned and an extremely rotated left incisor palatal fistula with loss of the maxillary upper inci-
tooth was derotated. The lesser segment was sors, canines, and second molars (Fig. 4A–C). Alve-
expanded by using arch wires (Fig. 1D–F). After olar distraction was planned to transport the mesial
11 months of fixed orthodontic treatment, a fabri- ends of both alveolar segments to the midline in or-
cated alveolar distractor was applied to the lesser der to reduce the cleft defect (Fig. 4D). A bilateral
segment. The activation rate was 0.5 mm/d with and simultaneous distraction was planned, and
424 Esenlik & DeMitchell-Rodriguez

Fig. 1. Case 1. (A–C) Preorthodontic view of a unilateral cleft lip and palate with transverse deficiency. (D–F)
Aligning the teeth presurgically, the fistula became larger. Yellow circle shows the collapsed lesser segment
(A). Yellow circle shows the fistula (D). (G–I) After alveolar distraction, the cleft gap was closed. Please note
that some gingival recession and gingival bulge occurred postoperatively. Black arrow shows the closed fistula
(G). (J) Predistraction panoramic view. A large cleft gap is seen. (K) The cleft gap has closed and new bone is
seen between the second premolar and the first molar teeth.

Liou Cleft Distractors were inserted between the maintaining the directed transport segment in its
premolars on the right and second premolar and new position. This period presents 3 main advan-
molar teeth on the left. A transpalatal bar was tages to clinicians: facilitating the tooth movement
used to guide the alveolar segments (Fig. 4E, F). into the new generated bone; improving bone matu-
An alveolar osteotomy was followed by a 3-week ration of the generate through orthodontic transpo-
activation period. Alveolar bone graft was per- sition of the teeth, increasing or reforming the
formed 8 months after the completion of AVO. Alve- residual bone; and (when required) correcting
olar bone graft was followed by 2 jaw surgeries as the displaced transported segment, or molding the
well as prosthetic rehabilitation (Fig. 4G–K). Five generate. The molding of the generate can be crucial
year-follow-up radiographs demonstrates stable to manage complications, such as collapsed or dis-
bone formation with limited resorption at the ante- located alveolar segments. Pichelmayer and
rior alveolus (Fig. 4L). Zemann26 reported a case of undergoing a distrac-
tion protocol in which maxillary arch was expanded
POSTDISTRACTION ORTHODONTICS by using a fixed expansion plate after collapsing the
segment transversally following the VAD.
Postdistraction orthodontics includes refinement of The distraction device generally is kept in place for
occlusion using elastics and TADs as well as 3 months to 4 months to maintain the new generated
 Alveolar Distraction 425

Fig. 2. Case 2. (A, B) Predistraction photographs after orthodontic preparation. (C–E) The angulation of the dis-
tractor is seen to obtain a curvilinear route. Some bonded material is added at the occlusal surface of the lower
molar teeth for bite jumping. The fistula and cleft gap were both reduced. Yellow arrow shows the transversal
angulation of the distractor and dotted line shows the occlusal plane (C). The yellow arrow shows the vertical
angulation of the distractor (D). (F) Presurgical panoramic radiograph. (G) Third month of the consolidation
period. (H) At the ninth month after active distraction period, new generated bone can be seen mesial and distal
to the right canine. (I) At 2 years after distraction, stable results can be seen.

bone. During this period, tooth movement easily can (appositional stimulation) is an important issue to
be done because the newly formed bone is not focus on. Bone regeneration can be augmented
mature yet. Aligning ectopic erupted teeth is facili- by orthodontic tooth transposition into the bony
tated at this time. Although there are different opin- generate, thereby increasing atrophic or insuffi-
ions about the timing of tooth movement into the cient alveolar bone volume.28 Liou and Chen8
new generated bone, the authors’ protocol entails demonstrated an improved alveolar height by
transposition 6 weeks after distraction.8,27 The au- closing the space with orthodontic tooth move-
thors believe this protocol accelerates tooth move- ment following an insufficient bone graft. There-
ment because the regenerate is soft. fore, the alveolar height obtained by the
In addition to aligning the teeth, stimulating the distraction can be improved by these same
generated bone through orthodontic techniques methods. Namely, the residual bone can be
426 Esenlik & DeMitchell-Rodriguez

Fig. 3. Case 3. (A) A patient with a bilateral cleft lip and palate with a large fistula. Yellow arrow shows the rudi-
mentary premaxilla (A). (B) After distraction osteogenesis, the cleft gap was reduced and the fistula was minimal-
ized. Yellow arrow shows te curvature of the distracted bone (B). The curvilinear movement was achieved by
orientation of the distractor. (C) At 5-year follow-up, the closed gap was stable. (D) Orientation of the screw is
seen. It is not located parallel to the vestibular surface and occlusal plane. Yellow arrow shows the transversal
angulation of the device and black arrow shows the vertical angulation of it (D). (E) A large cleft gap and
many lost teeth are seen in presurgical panoramic film. (F) Panoramic view just after the active distraction period.
A bone-borne and tooth-borne device is seen. (G) The distracted bone was maintained at 5-year follow-up.

remodeled by the postdistraction orthodontics, between the alveolar segments. In those cases,
and this period can benefit from refinement of the presurgical orthodontic preparation may take
the dentoalveolar structures. longer. The alveolar cleft may expand, after pre-
surgical orthodontics is completed.
COMPLICATIONS/DIFFICULTIES One of the challenges of device during place-
ment is that there may be an insufficient vestibular
Although the alveolar distraction method has many height to accommodate the device. The same de-
advantages, it can be a technically challenging vice is left intraorally during the activation and
procedure. Major complications include fracture consolidation period. Therefore, adequate vestib-
of the transport segment or surrounding bones, ular lining and oral hygiene are critical to limiting
nonunion of the bone segments, and infection. Mi- soft tissue complications associated with alveolar
nor complications include displacement of the distraction. Another challenge can be lack of skel-
transported segment, soft tissue breakdown, peri- etal anchorage to fix the distractor device. Patients
odontal recession, gingivitis, injured teeth adja- with cleft commonly have hard tissue deficiencies
cent to the osteotomy site, loss of anchorage, of the maxilla. Obtaining a 3-D skeletal model of
and debonding of the tooth-borne distractor dur- the patient before the operation and simulating de-
ing activation.29,30 Soft tissue problems can be vice placement can allow a clinician to determine
caused by soft tissue irritation/trauma due to the the secure areas to anchor surgical guides that
distraction device, inadequate soft tissue stretch- can be customized if needed. This allows shorter
ing according during activation, and periodontal operation time and a more predictable operation.
infections secondary to poor patient compliance. Virtual surgical planning also can be considered.
Patients with a cleft may have congenital Despite successful cases reported in the litera-
absence of 1 or more teeth that make the alveolus ture, some clinicians contend that ADO is a difficult
irregular and can lead to vertical discrepancies
 Alveolar Distraction 427

Fig. 4. Case 4. (A–C) A patient with unilateral cleft lip and palate with missing teeth at the anterior area and a
large fistula. (D) Transported segments are planned on the 3-D model. (E, F) Bilateral alveolar distraction with
bone-borne distractors. (G, H) At 5-year follow-up of alveolar distraction. (I) Presurgical radiograph of the patient
with a large cleft defect. (J) Transported segments are seen following the distraction. (K) At 2-year follow-up of
alveolar distraction. (L) At 5-year follow-up of alveolar distraction.

and unpredictable method due to the possibility of treatment of large and complex alveolar clefts;
displacement of the transport segment and diffi- however, it should be performed with a skilled or-
cultly in controlling activation. Most of the distrac- thodontic and surgical team with a high volume
tion devices move linearly, and the need for an and high complexity practice in cleft care.
arched path of distraction can be seen as chal-
lenge. Distracted alveolar segments tend to SUMMARY
deviate more palatally.30 These medial deviations
can be managed by using expansion appliances. ADO is a versatile technique that can be used as a
However inferior deviations of the alveolar staged treatment plan to close large and complex
segment, it may be difficult to intrude, necessi- alveolar clefts. This approach is used widely for
tating an additional procedure. alveolar augmentation in 3-D in both noncleft and
Additional surgeries are required after ADO to cleft populations. The technique reduces the size
restore the bone deficiency of the alveolar cleft of the alveolar cleft, transports additional soft tis-
and/or approximation of the segments to graft sue lining to the area of the alveolar cleft, and gen-
the area or to close the residual fistula. Approxi- erates new bone within the alveolus. These
mating of the cleft segments may not guarantee changes simplify future alveolar bone grafts, in-
a successful bone graft. The significant number crease the likelihood of success, provide a bony
of variables that must be considered is the great- platform for orthodontic treatment, and facilitate
est hurdle for the popularization of this technique.7 dental rehabilitation. A majority of cases require
The authors believe ADO has a critical role in the customized case-specific devices and route
428 Esenlik & DeMitchell-Rodriguez

planning. This technique should be considered in 6. Pérez-Sayáns M, Martı́nez-Martı́n JM, Chamorro-

patients with severe clefts; and, due to the Petronacci C, et al. 20 years of alveolar distraction:
complexity of the technique and the target patient a systematic review of the literature. Med Oral Patol
population, ADO should be performed only by Oral Cir Bucal 2018;23:e742–51.
skilled orthodontic/surgical teams with a signifi- 7. Agabiti I, Capparè P, Gherlone EF, et al. New surgi-
cant experience in cleft care. cal technique and distraction osteogenesis for anky-
losed dental movement. J Craniofac Surg 2014;25:
828–30.
CLINICS CARE POINTS 8. Liou EJ, Chen KT. Intraoral distraction of segmental
osteotomies and miniscrews in management of alve-
olar cleft. Semin Orthod 2009;15:257–67.
9. Keestra JA, Barry O, Jong L, et al. Long-term effects
 The effectiveness of ADO in bone and soft tis- of vertical bone augmentation: a systematic review.
sue lengthening is well established. J Appl Oral Sci 2016;24:3–17.
10. Ettl T, Gerlach T, Schüsselbauer T, et al. Bone
 This technique is used for approximating the
cleft segments and narrowing large fistulas resorption and complications in alveolar distraction
to facilitate the alveolar bone grafting. osteogenesis. Clin Oral Investig 2010;14:481–9.
11. Takahashi T, Funaki K, Shintani H, et al. Use of hori-
 The complication seen most frequently dur-
zontal alveolar distraction osteogenesis for implant
ing alveolar distraction is palatal displace-
ment of the transported segment. placement in a narrow alveolar ridge: a case report.
Int J Oral Maxillofac Implants 2004;19:291–4.
 Appropriate distraction route planning is crit-
12. Albrektsson T, Zarb G, Worthington P, et al. The
ical to success and case-specific distractor/
long-term efficacy of currently used dental implants:
distraction designs commonly are necessary.
a review and proposed criteria of success. Int J Oral
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ACKNOWLEDGMENTS 14. Denadai R, Seo HJ. Lo LJ Persistent symptomatic
anterior oronasal fistulae in patients with Veau type
The authors thank Dr Y. Findik, DDS, PhD; Dr T.
III and IV clefts: a therapeutic protocol and out-
Baykul, DDS, PhD; and Dr A. Aydin, MD, from
comes. J Plast Reconstr Aesthet Surg 2020;73:
Süleyman Demirel University, Isparta, for surgical
126–33.
part of the cases.
15. Borzabadi-Farahani A, Groper JN, Tanner AM, et al.
The nance obturator, a new fixed obturator for pa-
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