Distraction osteogenesis

Dr Naveen Dutt
Pg III yr
Contents
Introduction

History

Classification of distraction osteogenesis

Biological basis of distraction

Indication & contraindications

Orthodontic perspective of distraction.

Surgical technique

Advantages & disadvantages

Complicatons

Conclusion & References

 INTRODUCTION
For centuries, many different techniques have
been used in an attempt to modify bone growth,
both in terms of amount & the direction.

Of the several approaches, one method of gradual

bone distraction known as “Distraction
Osteogenesis” is a biological process of new bone
formation between the surfaces of osteotomized
bone segments that are gradually separated by
incremental traction.
HISTORY
1848- Hullihen-performed the 1st surgical procedure for the correction of a
craniofacial deformity.

1905- Concept of distraction conceived by Codvilla

1927-Rosenthal- performed the 1st mandibular osteodistraction by using an

intraoral tooth-borne appliance that was gradually activated over a period of 1
month.

1948-Crawford-applied gradual incremental traction to the fractured callus of the

mandible.
1951- Prof ilizarov introduced his technique of distraction in Siberia.

1959-Kole-described a method for surgically correcting an anterior open bite due

to maxillary anterior deformity.

1960-Kole-developed the rapid canine distraction method

1989-McCarthy- was the 1st to clinically apply extraoral distraction osteogenesis

ALESSANDRO CODIVILLA – 1905

LEROY ABBOT – 1927

ILIZAROV’S EXTERNAL RING FIXATOR

 CLASSIFICATION OF
DISTRACTION OSTEOGENESIS
 Distraction

Distraction Osteogenesis
epiphyolysis
Physeal
Distraction
Chondrodiatasis

Callotasis

Depending upon the place where tensional stress was induced (De Bartiani et al.,
1986).
 Distraction
osteogenesis

External Internal

Subcutaneous Unidirectional
Bidirectional
Multidirectional
Bone borne Intraoral
Submucosal
Extramucosal

Classification based on the Tooth borne

type of craniofacial distraction Bone borne
devices
Hybrid
 1 Mandibular distraction
5

Maxillary Distraction 2

3 Alveolar ridge distraction

Periodontal ligament 4

Distraction
5 Cranial Distraction
Bone Transport

Classification of craniofacial distraction according to sites

 Distraction
Osteogenesis

Uniplanar Multiplanar

Based on the plane in which the device works

Classification of Alveolar ridge distraction devices
 BIOLOGICAL BASIS OF
DISTRACTION OSTEOGENESIS
5 Sequential periods of Distraction
OSTEOTOMY
Recruitment of
osteoprogenitor cells

Cellular
modulation/Osteoinduction

Osteoconduction

Activation of inflammatory
mediators

(Ilizarov, 1989; Komuro et al., 1994; Aronson et al., 1990, 1997; Al-Aqs et al., 2008).
LATENCY

Vascular disruption

Haematoma

Clot & bony necrosis occurs at the

end of the fractured segments.

Clot is replaced lastly by granulation

tissue

Soft Callus
DISTRACTION PERIOD

Normal fracture healing is interrupted

Activates the biologic elements

Increased fibroblast proliferation

Increased Osteoblastic Activity

Bone formation
CONSOLIDATION

3 zones can be seen during the consolidation

phase.

2 radiolucent zones and one radio-opaque zone.

Radio-opaque zone consists of rich blood supply

and woven bone.

Proximal and distal to the radiolucent zone-

direct continuation of old bony edges.(
Transition zone called trabecular zone)

Consists of collagen fibres and preosteoblasts

which mature and help in mineralization of the
newly formed woven bone
REMODELLING

Bony trabeculae becomes thicker with a

mixture of lamellar and woven bone,
rimmed by osteoblast and bridging the
distracted gap from edge to edge.

Bone remodeling of newly formed bone by

osteoclastic resorption can also be seen
completing the whole process.
FACTORS AFFECTING DISTRACTION
OSTEOGENESIS
The factors that determine the local mechanical environment at the distraction site
include

A) Type of osteotomy (corticotomy versus osteotomy) :

Both periosteal and endosteal structures are important for bone healing. Hence,
corticotomy with preservation of intramedullary blood vessels is preferred.

A comparison of different corticotomy techniques in distraction osteogenesis done

by Paley (1990) showed no significant differences between a true corticotomy
technique and an osteotomy performed by multiple drill holes and osteotome.
B) Timing of distraction (immediate distraction versus delayed
distraction):

To optimize the response of osteogenic tissue to distraction, a latency period has

been suggested for early callus formation.

Different latency periods, ranging from 5 to 21 days, have been reported in clinical
trials and animal experiments.
C) Rate and rhythm of distraction:

A rate of 1.0mm per day of distraction force is appropriate in most cases.

In younger children, the rate is increased to 1.5 to 2.0mm per day.

In case of bifocal Distraction osteogenesis,the soft tissue can only support 1.0mm
of distraction force applied to two sites, for a total of 2mm per day.
D) Stability of fixation:

Stable fixation is important for adequate formation of microcolumns of bone during

Distraction osteogenesis.

Bending or shear forces seem to induce fractures of the microcolumns with local
hemorrhage and resultant histologic cartilage interposition.

Stable fixation which allows controlled axial compression or distraction is optimal.

INDICATIONS
Congenital Deformities

Pierre Robin syndrome

Distraction osteogenesis is required to

(1)prevent asphyxia and

(2)for correction of mandibular deficiency.

Treacher-Collins & Goldenhar syndrome
(iv)Severely constricted mandible in children and adults.

v) Congenital micrognathia-non-syndromic.

vi) Maxillary deficiency in operated cases of cleft lip and palate.

vii) Craniofacial microsomia-unilateral/bilateral.

viii) Midface hypoplasia.

ix) Obstructive sleep apnoea syndrome.

x) Severely constricted maxilla in adults.

xi) Facial asymmetry (Dale et al., 2007)

Acquired Conditions
1. Post-traumatic growth disturbance of the mandible

Example--- mandibular hypoplasia due to TMJ ankylosis.

2. Non-union of fractures.

3. Atrophy of edentulous segments.

4. Oncologic mandibular osseous defects.

CONTRA-INDICATIONS
1. Poor nutrition and lack of soft tissue.

2. Inadequate bone stock as in neonates.

3.Geriatric patients

4. Irradiated bone.

5. Osteoporotic bone.

6. Any systemic disease which affects bone metabolism

DIAGNOSIS & TREATMENT PLANNING
Clinical Evaluation

The function of the TMJ before distraction and the motor (muscles of mastication
and facial expression) and the sensory (inferior alveolar, infraorbital) nerve
functions of the patient are recorded.

A transient limitation to opening can occur after distraction. Thus it is important to

document mandibular excursion and original interincisal opening for use an
objective goal during post distraction physical therapy.
Diagnostic records
Photographs – Frontal, lateral, oblique, submental and intraoral.

Models

Lateral and anteroposterior (frontal) cephalograms

3D cephalometrics

★ The 3-D image can be rotated on the computer screen into typical views to
assess the degree of craniofacial skeletal asymmetry and to plan the surgical
distraction correction
ORTHODONTIC MANAGEMENT OF THE PATIENT
The role of orthodontics in treatment using distraction osteogenesis falls into three
temporal phases:

A. Predistraction treatment planning and orthodontic Preparation

B. Orthodontic therapy during distraction and consolidation

C. Post-consolidation orthodontic/orthopedic management

Pre-surgical Orthodontic Preperation
Orthodontic appliances are selected and treatment is initiated that is consistent
with the overall goals of the distraction treatment plan.

The teeth should be moved to ideal positions relative to basal bone so that an
ideal maxillomandibular skeletal relationship is not compromised by existing dental
compensations

Dental mal-relationships must be eliminated that would mechanically interfere with

the movement of the tooth-bearing segment during the gradual distraction
Selection of orthodontic appliance.

Initiation of treatment with the overall goals of the distraction treatment plan.

Elimination of dental malrelationships, to allow free movement of the tooth-bearing

segment during the gradual distraction

Movement of teeth to ideal positions relative to basal bone

Example 1: A patient with severe mandibular retrognathia may have a transverse
maxillary deficiency

In such cases, it is appropriate to expand the maxilla either before or during

distraction to accommodate the width of the advanced mandible.

Dental position and maxillary arch width should enhance the distraction, not inhibit
it.
Orthodontic Therapy During Distraction and
Consolidation
After completion of presurgical orthodontic preparation, the surgical procedure is
performed.

The latency period is allowed to elapse, and the distraction is initiated.

Active orthodontics/orthopedics may continue throughout the distraction and/or

consolidation phases.

The use of these appliances improves the quality of the surgical/orthodontic

result by directing the tooth-bearing segment toward its planned postdistraction
position.
In predistraction planning, the orthodontist evaluates and determines the desired
vector based on a skeletal appraisal.’

However, the clinically observed vector often varies from the planned vector.

Four influences that are presumed to affect the observed vector are:
(1) Biomechanical characteristics of the selected distraction device,

(2) Orientation of the distraction device to the mandibular anatomy,

(3) Neuromuscular influence, and

(4) Externally exerted forces.

Vertical elongation of the ramus achieved by placement of distractor
perpendicular or acute to the patient’s occlusal plane.

Placement of the distraction device parallel to the posterior border of the ramus
results in an oblique distraction.

If the distraction goal is to achieve both ramus and body lengthening, an

oblique vector is used. This may be achieved by placement of the device oblique
to the occlusal plane.

In the patient in whom deficiency is bilateral and symmetrical, it is necessary to

place the distraction devices in a bilaterally symmetrical position.
Calculation of the amount of distraction

The angle between these two sides is

the gonial angle and third side indicates
amount of distraction. This can be
calculated by using the formula:

•Distraction amount = Dc + Dr – 2 (Dc x

Dr) x Cos a

• Dc = Corpus deficiency
• Dr = Ramus deficiency
A = Gonial angle
Relationship between the orientation of the distraction device and the amount of
horizontal versus vertical net change achieved.

Hanson evaluated patients who had a total of 54 distraction devices placed.

Oblique placement - greater than 90° of angulation between the occlusal plane
and the long axis of the distraction device.

Oblique device placement showed anterior movement of the tooth-bearing

segment as measured at the level of the occlusion, with an average value of 2.5
mm.
Distraction devices with a multidirectional capability are able to alter the
observed vector as it deviates from the planned vector.

Another force presumed to affect the path of the tooth-bearing segment is

generated by the neuro-musculature.

Patients undergoing distraction develop functional compensations for their

gradually changing occlusions.

Often these patients will posture their mandibles anteriorly or laterally to pick up
occlusal contacts that have been lost during distraction to aid them in masticatory
function. These functional positional changes represent a recurrent force that is
likely to influence the path of the tooth-bearing segment
path of the tooth-bearing segment.

The orthodontist must recognize the presence of these influences and

compensate for them with orthodontic and/or orthopedic measures.
Orthodontic Management after Disctraction and
Consolidation
After,consolidation, the distraction device is removed and the tooth-bearing
segment of the mandible derives its support from the new bone that was
generated across the distraction gap.

Postdistraction orthodontics is initiated to accomplish the original treatment

goals.

The postdistraction orthodontic needs vary depending on whether the mandibular

distraction was unilateral or bilateral.
Treatment objectives will also include eruption guidance and alignment of the
dentition over alveolar bone.

Orthodontic treatment for growing children may need to take into consideration
future distraction or orthognathic surgery. In the nongrowing bilateral distraction
patient, orthodontic finishing is completed at this time.
There is, however, a population of patients in whom an orthognathic surgical
procedure may be indicated after mandibular distraction. These patients would
undergo surgical orthodontic preparation at this time.

In unilateral distraction patients, the postdistraction orthodontic therapy will most

likely involve occlusal plane management, correction of the dental midlines, and
correction of the maxillomandibular transverse disharmony.

Unilateral mandibular distraction usually requires intensive postdistraction

orthodontic support. This may include eruption guidance, alignment of the
dentition over alveolar bone. The mandibular occlusal plane must be maintained in
the corrected position that was achieved through mandibular distraction.
Methods of occlusal plane management include the use of:

(1) an occlusal acrylic wafer that is reduced one tooth at a time to allow for serial
eruption of the maxillary posterior dentition, and

(2) a functional appliance with lingual shields to provide lateral con-trol of

mandibular position.
A functional appliance provides interarch
control and prevents lateral shifting of the
mandible through lingual shields. It contains a
biteplane that is adjusted one tooth at a time for
serial supereruption of teeth. Elastic traction
improves e&ciency of occlusal plane correction
Posterior occlusal acrylic buildups on the
distracted side support the corrected
mandibular occlusal plane. Selective
reduction allows serial super- eruption of
the maxillary teeth. Interarch elastic
traction improves efficiency
SURGICAL TECHNIQUE
Planning for maxillary distraction osteogenesis

Mainly used in correction of

1.Unilateral cleft lip and palate

2.Bilateral cleft lip and palate.

3.Mandibular prognathism.

4.Nasomaxillary dysplasia.
Surgery

● Incision is made about 3-5cm in the maxillary vestibule leaving 2cm intact
mucosa
● Subperiosteal dissection is performed by pyrifom fossa to the lateral maxillary
buttress on each side to expose the anterior and lateral aspects of maxilla to
the level of infraorbital.
● Dissection of nasal floor is limited to lateral part only.
● Using bur incomplete osteotomy is performed above the roots of canine and
molar tooth buds
● The osteotomy extends upto maxillary buttress. Mucosa is then approximated
and closed.

Distraction protocol

● On the 5th postoperative day distraction forces are initiated using intraoral
device and a face mask supported by forehead and chin.
● Two elastic per side are attached from the vestibular hubs in the canine
region to a bar on the face mask.
● The initial distraction force delivered by elastic is 900gms which is applied by
the face mask for 16 to 18 hours/day.

● Once the maxilla is advanced to a satisfactory Class II molar relationship

amount of force decreased to one elastic band (450gm) for another 2 months.

● After about 8-10 weeks post distraction there is radiographic evidence of new
bone at corticotomy site.
ALVEOLAR RIDGE AUGMENTATION
RAPID CANINE DISTRACTION
DISTRACTION DEVICES
Intra oral distraction device

The intraoral device is usually

unidirectional. This device is usually
helpful for increasing ramus and
corpus length as well as the angle
between ramus and corpus.
 ADVANTAGES OF DISTRACTION
OSTEOGENESIS OVER ORTHOGNATHIC
SURGERY
1.The technique can be applied at a younger age (2 years).

2.Large maxillomandibular advancement is possible (Advancement >8mm)

3.Less possibility of relapse.

4.Shorter hospital stay.

5.Reduced postoperative pain and swelling.

6.Increased stability.

7.Reduced inferior alveolar nerve dyaesthesia.

8.Reduced need for intermaxillary fixation.

9.No bone graft is required.

DISADVANTAGES
1.Cannot be used in dysplasias due to excessive growth

2.Highly dependent on patient compliance

3.Multiple out-patient visits may be required in some cases.

4. Poor 3D control on the segments with current distracters.

5. Manipulation of healing corticotomy daily or several times a day could give rise
to pain.

6.Scarring can occur if extraoral approach is used

7. Difficult plaque control.

8. Damage to TMJ due to incorrect vector orientation.

9.Risk of infection
COMPLICATIONS
1.Ischaemic fibrogenesis.
2.Cystic degeneration.
3.Bending of regenerated bone.
4.Regenerated malformation.
5.Regenerated fracture.
6.Axial deviations.
7.Infections
CONCLUSION
Distraction osteogenesis offers a solution for surgical orthodontic management of
developmental anomalies of the craniofacial skeleton.

The orthodontist has a primary role in the planning and execution of treatment
for patients undergoing distraction osteogenesis.
Active orthodontic treatment is used before, during, and after distraction.
The types of orthodontic treatment are designed to address the unique
malocclusion.
The surgical and orthodontic distraction plan and treatment goals are jointly
developed between the orthodontist and the surgeon, very close follow-up by
both clinicians
REFERENCES
● Graber, Vanarsdall, Vig. Orthodontics: Current Principles and techniques. Mosby,4th edition

● Rapid canine retraction through distraction of the periodontal ligament; AJODO 1998; Liou,
Huang

● Pamela R. Hanson and Michael B. Melugin. Orthodontic Management of the Patient

Undergoing Mandibular Distraction Osteogenesis; Semin Orthod 1999;5:25-34,

● Guerrero et al. Intraoral Mandibular Distraction Osteogenesis; Semin Orthod 1999;5:35-40.

● Figueroa et al. Maxillary Distraction for the Management of Cleft Maxillary Hypoplasia With a
Rigid External Distraction System; Semin Orthod 1999;5:46-51.
● Grayson, Santiago.Treatment Planning and Biomechanics of Distraction Osteogenesis From
an Orthodontic Perspective; Semin Orthod 2000;5:9-24,

● Dheeraj et al. Modern practice in orthognathic and reconstructive surgery. J Public Health and
Epidemiol Vol. 3(4), pp. 129-137, April 2011

● Bavikati et al. Distaraction osteogenesis a review. Annals of esse Vol. VII Issue 1 Jan– Mar
2015.

● Aravind et al. Evolution of distraction osteogenesis in the oral and maxillofacial surgery
International Journal of Oral Health Dentistry, January-March, 2020;6(1):1-4
● Ramanathan, M., Kiruba, G.A., Christabel, A. et al. Distraction Osteogenesis Versus
Orthognathic Surgery: Demystifying Differences in Concepts, Techniques and
Outcomes. J. Maxillofac. Oral Surg. 19, 477–489 (2020).
Questions?

Define distraction osteogenesis?

Classify distraction osteogenesis.

Benefits of distraction over orthognathic surgery?

Drawbacks of distraction?

When to choose distraction?

Who introduced the concept of distraction?

Vectors of distraction?

Amount of distraction (formula)?

Alveolar augmentation

Rapid canine distraction

Thank you