Maxillary reconstruction after tumor resection is an important challenge for oncological surgeons, since obtaining soft tissue and bony tissue at the same time implies, on most occasions, the use of free flaps in order to obtain enough volume to carry out an implant-supported rehabilitation.¹

The application of osteogenesis techniques by distraction for reconstructing the alveolar process was described by Block² on dogs and by Chin³ on humans. Since then, multiple descriptions of intraosseous and juxtaosseous distractor designs have appeared, and the technique has also been applied on toothed or edentulous segments.

One of the uses of osteogenic distraction both with long bones and mandibles has been for the reconstruction of segment defects, and this same technique has been used for maxillopalatine fissure closure.⁴

The application of this technique for reconstructing other kinds of segment defects in the maxilla is less common.^5,6 Yet, it can be an excellent alternative in those cases in which obtaining a good segment for carrying out the transport is possible, and when a safe resection with regards to the tumor is guaranteed, as has already been attested in the case of the mandible bone.⁷

Case report

A Bichat’s fat-pad flap was used for reconstructing the soft tissue (Fig. 3) and the alveolar process osteotomy was planned distally from tooth 2.2, including in the segment teeth 2.3 and 2.4. Care was taken to maintain the point of union with the palatine mucoperiosteum in order to guarantee blood circulation in the fragment, which is essential for the success of the treatment.⁸

A MODUS^® modular distractor (Medartis AG, Basel, Switzerland) and a 15 mm. rod in open position were placed so as to execute the transport by closing the distractor. In order to secure the distraction vector, an intermaxillary fixation screw and a 4 1/2 ounce orthodontic band were put in place⁹ to prevent the vector from veering in an occlusal and palatine direction, which is commonly observed during the distraction process in the anterior sections of the maxilla (Figs. 4 and 5).

After a consolidation phase that lasted 10 weeks, two implants measuring 4.1 by 12 mm, Esthetic plus, ITI^® system (Straumann AG, Waldenburg, Switzerland) (Fig. 7) were placed. These were rehabilitated 16 weeks later with a screw-retained SynOcta^® prosthetic abutment system (Straumann AG, Waldenburg, Switzerland). Endodontic treatment of teeth 2.3 and 2.4 was carried out, which were then covered with a porcelain crown with a morphological compound of a second premolar and first molar, respectively, even though pulp vitality tests were positive.

Then, on removing the distractor, a graft of connective tissue harvested from the tuberosity of the right maxilla was placed for aesthetic improvement, because the neck of the implant in the mesial position was visible after the restoration (Fig. 8). This resulted in stability both in the mucosa and in the osseous region, with the implants behaving as though they had been attached to original bone, with a bone loss of less than 0.1 mm after 12 months (Fig. 9).

Discussion

The efficiency of distraction osteogenesis for transporting a segment of the maxilla was proved in this case, both from the aesthetic and functional point of view. Excellent results were achieved using a technique that is less aggressive and that has a reasonable economic cost. It can be carried out simultaneously with resection surgery and it is also recommended for mandibular resection.⁶

The experimental studies carried out show that there is enough bone formation, both radiologically and histologically, to permit implant placement three months after callus consolidation, which also occurs in reconstructions by means of vertical distraction.¹⁰ The reconstruction of relatively large defects without resorting to grafts is also facilitated.^11,12 Great advantages can be seen in the application of this technique (as well as in other applications described) given that no donor sites are needed as vital bony tissue is used resulting in a simultaneous gain of soft tissue. As a result we believe that it should be included in the therapeutic arsenal for reconstructing the maxilla,⁶ in the same way that it is used for mandibular reconstruction.

It is important to emphasize the fact that the treatment of bone defects by distraction osteogenesis can be carried out on patients likely to require combined therapy including surgery and radiotherapy.^13,14 In these cases hyperbaric oxygen may be used as adjuvant treatment,¹⁵ although the necessary time for the callus to mature is greater than in patients that do not undergo radiotherapy.¹⁴

Conclusion

Dirección para correspondencia
Dr. Arturo Bilbao Alonso
Servicio de Cirugía Oral y Maxilofacial.
Hospital de Conxo.
Ramón Baltar s/n
15705 Santiago de Compostela, España
e-mail Arturo.Bilbao.Alonso@Sergas.es

Recibido: 27.06.2005
Aceptado: 21.11.2005

References

1. Ferrari S, Raffaini M, Caradonna L, Sesenna E. Secondary reconstruction, after maxillectomy, using an osteocutaneous flap from the fibula. Report of a case. Minerva Stomatol 1997;46:547-51.        [ Links ]

2. Block MS, Chang A, Crawford C. Mandibular alveolar ridge augmentation in the dog using distraction osteogenesis. J Oral Maxillofac Surg 1996;54:309- 14.        [ Links ]

3. Chin M, Toht BA. Distraction osteogenesis in maxillofacial surgery using internal devices: Review of five cases. J Oral Maxillofac Surg 1996;54:45-53.        [ Links ]

4. Dolanmaz D, Karaman AI, Durmus E, Malkoc S. Management of alveolar clefts using dento-osseus transport distraction osteogenesis. Angle Orthod 2003;73: 723- 29.        [ Links ]

5. Cheung LK, Zhang Q. Healing of maxillary alveolus in transport osteogenesis for partial maxillectomy. J Oral Maxillofac Surg 2004;62:66-72.        [ Links ]

6. Cheung LK,Zhang Q, Zhang ZG, Wong MC. Reconstruction of maxillectomy defect by transport distraction osteogenesis. Int J Oral Maxillofac Surg 2003; 32:515-22.        [ Links ]

7. Takahashi T, Fukuda M Aiba T, Funaki K, Ohnuki T, Kondoh T Distraction osteogenesis for reconstruction after mandibular segmental resection. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:21-6.        [ Links ]

8. Chin M: Distraction osteogenesis for dental implants. Atlas Oral Maxillofac Clin North Am 1999;7:41-63.        [ Links ]

9. Bilbao A. Regeneración del proceso alveolar: Distracción ósea. Rev Esp Cirug Oral y Maxilofac 2002;24:298-303.        [ Links ]

10. Cheung LK, Zhang Q. Radiologic characterization of new bone generated from distraction after maxillary bone transport. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:234-42.        [ Links ]

11. Henkel KO, Ma L, Lenz JH, Jonas L, Gundlach KK. Closure of vertical alveolar bone defects with guided horizontal distraction osteogenesis: an experimental study in pigs and first clinical results. J Craniomaxillofac Surg 2001;29:249-53.        [ Links ]

12. Liou EJ, Chen PK, Huang CS, Chen R. Interdental distraction osteogenesis and rapid orthodontic tooth movement: a novel approach to approximate a wide alveolar cleft or bony defect. Plast Reconstr Surg 2000;105:1262-72        [ Links ]

13. Klesper B, Lazar F, Siessegger M, Hidding J, Zoller JE. Vertical distraction osteogenesis of fibula transplants for mandibular reconstruction a preliminary study. J Craniomaxillofac Surg 2002;30:280- 5.        [ Links ]

14. Holmes SB, Lloyd T, Coglan KM, Newman L. Distraction osteogenesis of the mandible in the previously irradiated patient. J Oral Maxillofac Surg 2002;60:305-9.        [ Links ]

15. Muhonen A, Muhonen J, Lindholm TC, Minn H, Klossner J, Kulmala J, Happonen RP. Osteodistraction of a previously irradiated mandible with or without adjunctive Hyperbaryc oxygenation; an experimental study in rabbits. Int J Oral Maxillofac Surg 2002;31:519-24.        [ Links ]