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Balancing Distraction Forces in The Mandible .22
Balancing Distraction Forces in The Mandible .22
Pediatric/Craniofacial
Balancing Distraction Forces in the Mandible:
Newton’s Third Law of Distraction
Sameer Shakir, MD*
Sanjay Naran, MD† Summary: Vertical mandibular distraction results in translation of both proximal
Kristen M. Lowe, DDS, MS* and distal segments. The force exerted on the condylar segment not only places un-
Scott P. Bartlett, MD* wanted force on the joint but also rotates the coronoid process into the cranial base.
To prevent these sequelae, we investigate the use of a "check plate" on the condylar
segment in an attempt to decrease force at the Temporomandibular joint (TMJ)
Downloaded from https://journals.lww.com/prsgo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3fgGGXf0fUkC7v+klQrMrqvHJ/9YSceg6l9WcsDEL1FjvHPy3AZzPfA== on 02/21/2019
and prevent unwanted rotation of the coronoid. Patients with hemifacial microso-
mia, seen at our Children's Hospital from 2012 to 2016 having undergone unilateral
vertical mandibular distraction with placement of check plate were compared with
a sample of those similarly having undergone distraction without use of the plate.
Preoperative and postoperative cephalometric measures and 3-dimensional com-
puted tomography imaging were analyzed. Three subjects were identified in each
group. Age and Pruzansky-Kaban classification did not differ between groups. Ver-
tical distance from the coronoid process perpendicular to the Frankfort Horizontal
did not differ between groups (P < 0.07); however, postoperative distance signifi-
cantly differed with the coronoid process rotating upward into the cranial base in
subjects without a check plate (P < 0.005). Preoperative angle of the coronoid pro-
cess based on the Frankfort Horizontal did not differ (P < 0.06); however, postoper-
ative angle significantly changed, confirming upward rotation into the cranial base
(P < 0.01). Total regenerate did not differ (P < 0.08). Vertical mandibular d
istraction
results in undesirable upward rotation of the proximal segment into the cranial
base and superior displacement of regenerate. This can be prevented with the
use of a check plate. (Plast Reconstr Surg Glob Open 2018;6:e1856; doi: 10.1097/
GOX.0000000000001856; Published online 14 September 2018.)
www.PRSGlobalOpen.com 1
PRS Global Open • 2018
and optimize the position of the regenerate along the newly and average time between preoperative and postoperative
lengthened ramus. CT imaging did not differ between groups.
2
Shakir et al. • Balancing Distraction Forces in the Mandible
Fig. 2. Check plate prevents upward rotation of the proximal mandibular segment during vertical dis-
traction. A, Postoperative 3D CT depicting preserved anatomic position of the proximal mandibular
segment (green outline) with relation to the cranial base in a subject having undergone distraction
with a check plate. B, Proximal mandibular segment (green outline) with superior rotation abutting the
cranial base in a subject having undergone distraction without use of a check plate. (*Red line repre-
senting the FH was created from the unaffected side.)
Use of a check plate was not associated with these com- Scott P. Bartlett, MD
plications. In a larger cohort with longer follow-up, check Children’s Hospital of Philadelphia
plate use may translate to a reduction in more frequently University of Pennsylvania
associated long-term outcomes such as ankylosis and im- 3400 Civic Center Boulevard
paired TMJ function. Philadelphia, PA 19104
We acknowledge several study limitations. Our small E-mail: bartletts@email.chop.edu
sample size and lack of power prevents us from drawing
generalizable conclusions. We present short-term follow- REFERENCES
1. McCarthy JG, Schreiber J, Karp N, et al. Lengthening the human
up data; long-term results will allow for additional com-
mandible by gradual distraction. Plast Reconstr Surg. 1992;89:1–8;
mentary on the incidence of malocclusion, need for discussion 9.
orthognathic correction, TMJ function, and further com- 2. Verlinden CR, van de Vijfeijken SE, Jansma EP, et al. Complications
ment on the “adaptive” nature of the mandibular condyle. of mandibular distraction osteogenesis for congenital deformities:
a systematic review of the literature and proposal of a new classifi-
cation for complications. Int J Oral Maxillofac Surg. 2015;44:37–43.
CONCLUSIONS 3. Master DL, Hanson PR, Gosain AK. Complications of mandibu-
Fixation of a check plate to engage the zygomatic arch lar distraction osteogenesis. J Craniofac Surg. 2010;21:1565–1570.
during traditional vertical mandibular may prevent un- 4. Feng S, Zhang Z, Shi L, et al. Temporal bone resorption: an un-
desirable and potentially harmful upward rotation of the common complication after mandibular distraction. J Craniofac
proximal segment and regenerate displacement. Surg. 2015;26:e185–e187.
3
PRS Global Open • 2018
5. Ascenço AS, Balbinot P, Junior IM, et al. Mandibular distraction 8. Gunbay T, Akay MC, Aras A, et al. Effects of transmandibular
in hemifacial microsomia is not a permanent treatment: a long- symphyseal distraction on teeth, bone, and temporomandibular
term evaluation. J Craniofac Surg. 2014;25:352–354. joint. J Oral Maxillofac Surg. 2009;67:2254–2265.
6. Hollier LH, Kim JH, Grayson B, et al. Mandibular growth after 9. Guerrero CA, Bell WH, Contasti GI, et al. Mandibular widening
distraction in patients under 48 months of age. Plast Reconstr by intraoral distraction osteogenesis. Br J Oral Maxillofac Surg.
Surg. 1999;103:1361–1370. 1997;35:383–392.
7. Suh J, Choi TH, Baek SH, et al. Mandibular distraction in uni- 10. Fan K, Andrews BT, Liao E, et al. Protection of the temporoman-
lateral craniofacial microsomia: longitudinal results until the dibular joint during syndromic neonatal mandibular distraction
completion of growth. Plast Reconstr Surg. 2013;132:1244–1252. using condylar unloading. Plast Reconstr Surg. 2012;129:1151–1161.