J Oral Maxillofac Surg

60:389-394, 2002

Dentoalveolar Distraction Osteogenesis

for Rapid Orthodontic Canine Retraction
Reha S. Ksnsc, DDS, PhD,* Haluk Iser, DDS, PhD,
Hakan H. Tu
z, DDS, PhD, and Ayse T. Altug, DDS
Purpose:

We present a technique to reduce the overall orthodontic treatment time by means of

dentoalveolar distraction osteogenesis.
Patients and Methods: Eleven patients who were planned to undergo orthodontic treatment with
bilateral first premolar extractions and subsequent bilateral canine tooth distalization underwent osteotomy around the canine tooth. The first premolar was extracted, and the buccal bone was carefully
removed. After wound closure, a special orthopedic device was mounted and cemented to the first molar
and canine teeth. Distraction was started the same day at the rate of 0.4 mm twice a day and continued
until adequate movement of the canine teeth was achieved. The device was then removed, and
orthodontic therapy was continued with fixed appliances.
Results: The distraction rate and the device were well tolerated by all of patients. No anchorage loss
in the second premolar and first molar teeth, root resorption, dental ankylosis, discoloration, or loss of
vitality was detected.
Conclusion: The concept of distraction osteogenesis for rapid orthodontic tooth movement is promising and feasible for clinical practice.
2002 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 60:389-394, 2002
Distraction osteogenesis is a gradual bone-lengthening technique that was first introduced by Codivilla1
in 1905 and was popularized in the 1970s by the
extensive work of Ilizarov2 in orthopedics. In 1992
McCarthy et al3 reported the first clinical application
of distraction osteogenesis for mandibular lengthening to correct a facial deformity. Various indications in
the oral and maxillofacial region were subsequently
described.3-6 External devices were initially used for
distraction osteogenesis. The devices for intraoral applications were introduced shortly afterward, and
newer applications have been fostered.7-9 Intraoral
distraction osteogenesis has been used for lengthening, widening, and augmentation to correct several
skeletal problems.10-14

Conventional orthodontic treatments with either

fixed or functional appliances rely on biological tooth
movements.15 However, using conventional techniques, biological tooth movement can be achieved at
a limited rate.16 This feature is thought to be a shortcoming, especially when major tooth relocation is
necessary. The time required for tooth movement
within the alveolar bone may lengthen the overall
orthodontic treatment time. In this clinical report, we
describe a surgical technique for rapid tooth movement. The principles of distraction osteogenesis by
means of transportation of a bone disc are used to
move a dentoalveolar segment. The aim of this clinical
study was to establish an approach to reduce the
overall orthodontic treatment time by means of dentoalveolar distraction osteogenesis.

Received from Ankara University, Dental School, Ankara, Turkey.

*Professor, Department of Oral and Maxillofacial Surgery.
Professor, Department of Orthodontics.
Chief Resident, Department of Oral and Maxillofacial Surgery.
Research Assistant, Department of Orthodontics.
Address correspondence and reprint requests to Dr Kisnisci:
Ankara Universitesi, Dis Hekimligi Faku
ltesi, Besevler, Konya Yolu
zeri, 06500, Ankara, Turkey; e-mail: kisnisci@tr.net
U

Patients and Methods

Eleven patients (13 to 18 years old, 7 females and 4
males) scheduled for orthodontic treatment with bilateral bicuspid extractions and subsequent bilateral
canine tooth distalization underwent the procedure
that we describe. Patients and their parents were
informed about the proposed treatment plan involving the surgical phase as well as the conventional
alternative option, and their consent was obtained.
The surgery was carried out in the maxilla (8 patients)

2002 American Association of Oral and Maxillofacial Surgeons

0278-2391/02/6004-0007$35.00/0
doi:10.1053/joms.2002.31226

389

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DENTOALVEOLAR DISTRACTION OSTEOGENESIS

or the mandible (2 patients), and 1 patient underwent

the procedure in both jaws.
TECHNIQUE

An intraoral device for dentoalveolar distraction

osteogenesis was custom designed to enable canine
tooth distalization. When a unidirectionally moving
shaft on the device is activated a full turn, it closes 0.4
mm, moving the canine tooth posteriorly toward the
second premolar. The device was soldered to the
canine and first molar bands on a plaster model and
checked for fit and tolerance in the clinical setting.
All patients underwent surgery on an outpatient
basis with the use of local anesthesia, sometimes
supplemented with sedation. A horizontal mucosal
incision 2 to 2.5 cm long was made parallel to the
gingival margin of the canine and bicuspid teeth well
beyond the depth of the vestibule. Subperiosteal elevation was carried out to expose the canine root and
the first premolar region. A vertical osteotomy was
made on the anterior aspect of the canine tooth to be
distracted posteriorly using multiple cortical holes
made on the alveolar bone with a small, round, carbide bur under copious irrigation (Fig 1). The depth
and location of the cortical holes were dictated by the
proximity of the neighboring tooth. The osteotomy
was continued and curved apically, passing 3 to 5 mm
from the apex, which could readily be identified in
the alveolar bone. A vertical osteotomy was made in a
similar manner along the posterior aspect of the ca-

FIGURE 1. Vertically aligned multiple cortical holes on the medial

and lateral aspects of the upper right canine root in the level corresponding to the mid portion of the canine root, continuing and curving
apically and passing 3 to 5 mm from the apex.

FIGURE 2. Root of the upper right canine tooth is outlined medially

and distally at the apical region after the use of a thin and tapered
fissure bur to connect the holes.

nine tooth. A thin, tapered fissure bur was then used

to connect the holes around the canine root (Fig 2).
The root of the canine tooth thus was outlined anteriorly and posteriorly with a cone shape at the apical
region. Fine osteotomes were then introduced and
advanced in the coronal direction. The first premolar
was extracted at this stage, and the buccal bone was
carefully removed through the extraction socket using large, round burs between the bone cut at the
distal canine region anteriorly and the second premolar posteriorly. The bone apical to the extraction
socket and possible bony interferences at the buccal
aspect that may be encountered during the distraction process were eliminated and/or smoothed between the canine and the second premolar teeth with
preservation of palatal or lingual cortical shelves (Fig
3). The cortical bone at the apical region was also
relieved for maximal bodily movement during distraction. In cases in which the apex was closely situated
at or above the antrum floor, the bone between and in
front of the moving axis of the root was removed or
thinned out using round burs, with the maxillary
sinus lining exposed to facilitate posterior movement
of the dentoalveolar segment. Osteotomes in appropriate sizes were then used along the anterior aspect
of the dentoalveolar segment that includes the canine
tooth to split the surrounding spongy bone around its
root off of the lingual or palatal cortex and neighboring teeth. The transport dentoalveolar segment in-

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KISNISCI ET AL

cludes the buccal cortex and the underlying spongy

bone that envelops the canine root, leaving an intact
apical, lingual, or palatal cortical plate. Minimal force
was necessary for full mobilization of the transport
bone disc. The wound was irrigated with saline and
closed in a single mucosal layer with an absorbable
suture. The distraction device was fitted and cemented to the first molar and canine teeth at the end
of the surgical procedure. The patients were prescribed an antibiotic and a nonsteroidal anti-inflammatory drug for 5 days.
Dentoalveolar distraction was started on the day of
the surgery and continued at a rate of 0.4 mm twice a
day. It was discontinued when the canine tooth
moved posteriorly into the desired position (Figs 4,
5). The device was then removed, and orthodontic
therapy was continued with fixed appliances.

Results

FIGURE 3. Intraoperative view of the extraction socket of first premolar and upper right canine teeth carrying the dentoalveolar segment to
be used as a transport disc. The cortical bone, especially at the level
of the apical region, should also be eliminated for maximal bodily
movement during distraction.

The follow-up period ranged from 4 to 11 months.

The canine teeth were moved posteriorly or posteroinferiorly and made contact with the second premolars in 8 to 12 days. The distraction rate of 0.8 mm per
day and the device were well tolerated. Clinically, the

FIGURE 4. Dentoalveolar distraction of the right lower canine tooth.

A, Initial view before treatment. B, Day 3 of the distraction. C, Day 8
of the distraction.

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DENTOALVEOLAR DISTRACTION OSTEOGENESIS

FIGURE 5. Dentoalveolar distraction of the right upper canine tooth.

A, Initial view before treatment. B, Day 2 of the distraction. C, Day 9
of the distraction.

tooth-borne distraction devices did not cause any

movement of the lateral incisors or second premolars.
Root resorption and dental ankylosis were not detected in any of the patients (Figs 6, 7). No discoloration or radiographic evidence suggestive of loss of
tooth vitality was noted. Vitality testing after the removal of orthodontic fixed appliances proved to be in
normal ranges. In cases in which the bone had to be

FIGURE 6. Radiographic appearance of the upper right canine tooth

(A) before dentoalveolar distraction, and (B) during fixed orthodontic
treatment phase at a later stage, delineating new bone regenerated
mesially.

FIGURE 7. Panoramic radiograph of a patient with bilateral upper

canine teeth. A, Before dentoalveolar distraction. B, Immediately after
dismounting of the distraction device; also shows parallel posterior
movement.

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KISNISCI ET AL

removed down to the antral lining, none of the patients complained about sinus symptoms.

Discussion
The clinical applications of distraction osteogenesis
in maxillofacial surgery are becoming broader, and
several innovative techniques have been introduced
to change the classic approaches or to optimize the
correction of several deformities. In this clinical report, the reduced overall treatment time with this
technique may be considered an advantage. Conventional orthodontic tooth movement is the result of
biological cascades of resorption and apposition secondary to mechanical forces.17 Individual factors,
such as the optimum force, turn over in the periodontal ligament, and bone metabolism plays a role in
determination of the rate of tooth movement.18 However, the maximum rate of biological tooth movement
has been found to be similar even with different
magnitudes of forces.18 Classically, canine tooth distalization occurs at a rate of about 1 mm per month.
Therefore, in cases in which premolar extractions are
deemed necessary as part of the orthodontic treatment plan, the canine tooth distalization period takes
approximately 6 to 8 months.
To shorten the amount of time necessary for orthodontic tooth movement, various attempts have been
made. In 1998 Liou and Huang19 presented a rapid
canine retraction technique after extraction of the
first premolars through weakening of the interseptal
bone. The described canine tooth retraction technique was actually achieved through stretching of the
periodontal ligament.
Hyalinization as a result of pressure results in permanent damage and plays a major role as a ratelimiting factor in the orthodontic movement of
teeth.20 Tissue and fibrous elements may become
compromised during orthodontic treatment; this
seems to be related to local injury of the periodontal
ligament.21 It has been shown experimentally that
decreased vascular supply occurs when the magnitude of tension forces is exceeded, resulting in cell
death within the vicinity of the stretched fibers. Resorption of Sharpeys fibers, vascular invasion of
cells into the periodontal membrane, resorption of
alveolar bone, and reduction in alveolar bone thickness and height were also inevitable in regions of
tension.17,20
With our surgical technique, the dentoalveolus is
designed as a bone transport segment for posterior
movement. Vertical corticotomies were performed
around the root of canine teeth, followed by splitting
of the spongy bone around it. Therefore, the design of
the surgical technique does not rely on periodontal

stretching, which obviates overloading and stress accumulation in these tissues.

Patient compliance for social and professional reasons, especially in adults, may be a shortcoming because of the prolonged treatment time for orthodontic tooth movements. There also are some
contraindications for tooth movement using orthodontic treatment, including short roots, inability to
retain individual teeth after movement, and risk of
periodontal attachment loss. These may limit the
therapeutic goals and cause abandonment of treatment before ideal results are obtained.22,23 The
technique that we describe here may have applicability for those who seek rapid orthodontic therapy
or for patients who are good candidates to receive
conventional treatment. The concept of distraction
osteogenesis for rapid orthodontic tooth movement
is thought to be promising and feasible for clinical
practice.

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