DISTRACTION OSTEOGENESIS

PRESENTED BY DR RISSHI BHATT

GUIDED BY PROF.HOD.DR. S.M.AGRAWAL

CONTENT
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INTRODUCTION HISTORY BIOMECHANICAL PARAMETER BIOLOGIC PARAMETER CLASSIFICATION SEQUENTIAL PERIOD OF DO STAGES OF # HEALING EFFECT OF DO ON SKELETAL MUSCLE EFFECT OF DO ON PERIPHERAL NERVE EFFECT OF DO ON TMJ DISTRACTION DEVICES INDICATION & CONTRAINDICATION

    TREATMENT PLANNING COMPLICATION CONCLUSION REFRENCES .

INTRODUCTION Samchukov et al.. 1998 described Distraction osteogenesis as a biologic process of new bone formation between the surfaces of bone segments that are gradually separated by incremental traction The traction generates tension that stimulates new bone formation parallel to the vector of distraction .

.HISTORY AND EVOLUTION DO evolved from three procedures skeletal traction bone segment fixation osteotomy tech.

First described by CODIVILLA in 1905 on femur .

tension stress effect 2. influence of blood supply .GAVRIL ILIZAROV (1951) Ilizarov effects : 1.

Bone regenerates within the distraction gap is always formed along the vector of applied traction.ILIZAROV’S EXPERIMENTS Stable fixation with preserved axial micromotion generates membranous bone formation. . Preservation of osteogenic tissue during osteotomy.

5mm/day : premature consolidation 1.5mm/day : local ischemia Blood supply must be proportional to mechanical loading. .Bone formation depends on both rate and rhythm 0.

Mc Carthy & colleagues were the first to clinically apply extra oral distraction osteogenesis on four children with congenital abnormalities. Latency period – 7 days Distraction – 1mm/day in two increments Consolidation – 10 weeks .

one pin fixation on either side .Guerrero (1990) devolped his mid symphyseal mandibular widening technique. Molina & Ortiz simplified the method of Mc Carthy .corticotomy with medial cortex intact .

Extrinsic Intrinsic Device orientation Vector orientation . 2.BIOMECHENICAL PARAMETERS 1. 4. 3.

Rate and rhythm Consolidation 7. Proportional relationship between loading and newly formed bone . 3. Osteotomy Latency period Fixation Direction of distraction 5. 6.BIOLOGICAL PARAMETERS 1. 4. 2.

Bidirectional 3. Unidirectional 2. Tooth borne . Bone borne 2.Distraction device classification DISTRACTION DEVICE CLASSIFICATION Craniofacial Distraction Devices External Internal Bone borne 1. Multidirection al Subcutaneo us Intraoral 1.

Unidirectional device .

Bidirectional device .

Multidirectional device .

Intra oral device .

remodeling . osteotomy 2. distraction 4. latency 3. consolidation 5.Sequential periods of DO: 1.

Bone physiology Process of bone formation is called osseogenesis Intramembranous Endochondral .

remodeling .inflammation .6 steps of # healing: .soft callus .induction .impact .hard callus .

Young’s modulus of bone has been found to be 19.HOW DISTRACTON OSTEOGENESIS WORKS The bone is a viscoelastic material.4 GPa longitudinally and 15. A series of mechanical tests have revealed its Young’s Modulus. which means that it has viscous as well as elastic properties.0 GPa transversely.. . Which is pertinent information for the design of the distraction device.

and after about 3-4 % strain.htm . The collagen will plastically deform at the projected value of approximately 1 mm per day. is much greater than this value. Because the strain acting on the soft tissue in the distraction gap. during distraction osteogenesis.globalmednet.Young’s Modulus for collagen is found to be approximately 1000 MPa. the collagen no longer acts elastically. Foundation: Distraction Regenerate” http://www.com/do-cdrom/Biol/Histomor/rh07. it only deforms plastically.

000 2000 microstrains 20.hyper physiologic Woven lamellar bone Trabecular pattern Fibrous - .000 microstrains 200.physiologic .000 microstrains Multiple increments .Strain .higher extent of bone formation > 20.000 .chondroid formation -Ulrich Mayer et al .> 10.2000-3500 .

STRAIN .000 microstrains with 10 cycles/day – fast results AUTOMATED DISTRACTORS -Ulrich Mayer et al .stimulatory effects increased callus formation increased osteoblast proliferation 20.

osteoconduction .osteoinduction .OSTEOTOMY Division of bone in two segments Triggers bone healing ( # healing ) .recruitment of osteoprogenitor cells .

LATENCY PERIOD Period from bone division to onset of traction Represents time allowed for callus formation Sequence of events -Hematoma -Clot -Bone necrosis at the ends of # segments .

Ingrowths of vasoformative elements & cellular proliferation Stage of inflammation ( 1-3 days ) clot is replaced by granulation tissue

5 th day minicellular network of growing capillaries is formed In medullary canals of both

# segments.
granulation tissue is converted to fibrous tissue

Cartilage also replaces the granulation tissue – more
towards periphery

Inflammation leads to soft callus stage
-callus formation is the response of determined osteoprogenitor cells originating in periosteum and endosteum

role of callus formation Enlarges the diameter of segments Serves as solid base for new bone formation .it depends on many factors like: cytokines and growth factors ..

.DISTRACTION PERIOD Application of traction forces to osteotomised bone segments. Bone segments are gradually pulled apart resulting in formation of new bone tissue with in progressively increasing inter segmentary gap.

shape forming effect . .growth stimulating effect .changes at cellular and sub cellular level . .Normal # healing: -fibrocartilagenous tissue of Distraction : -normal process of healing is interrupted by application of gradual soft callus is replaced by osteoblasts into hard callus.stage hard callus lasts for 3-4 months followed by remodeling. traction which leads to microenvironment.

Growth stimulating effect: .polarization of these distraction fibroblasts parallel to vector of distraction.prolongation of angiogenesis .soft callus becomes longitudinally oriented along the axis of distraction . .causes altered phenotypic expression of fibroblasts ( distraction fibroblast ) .increased fibroblast proliferation Shape forming effect: .

Between 3-7 day of distraction capillaries grow into fibrous tissue During the 2nd week of distraction primary treabeculae begins to form .

Osteogenesis is started at existing bone wall and progress towards the center of distraction gap. By the end of 2nd week osteoid begins to mineralize .

CONSOLIDATION PERIOD Time between cessation of traction and removal of distraction devices. This period represents the time required for complete mineralization .

Distraction regenerate forms predominantly via membranous ossification. .

.REMODELING PERIOD Period from the application of full functional loading to the complete remodeling of newly formed bone.

Last stage of cortical reconstruction normalizes the bony structure ( 1 year ) .

EFFECT OF DISTRACTION ON SKELETAL MUSCLES Muscle orient in a plane parallel to distraction force & adapt with compensatory regeneration. ( Guerrirre & co workers ) .

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.Sarcomere is the smallest unit of muscle contraction.

. During distraction fibers of the attached muscles undergo incremental gradual stretching of muscle fibers which in turn stretches the sarcomeres increasing their length.Force devolped by muscle during isometric contraction is dependent on sarcomere length.

compromising muscle function. .Diminishes the number of connecting bridges between actin and myosin. To preserve muscle function sarcomeres must return to optimal range.

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75mm – 1mm per day) More fractioned rhythm leads to less muscle injury Mizumoto & coworkers .Slower rate leads to good muscle adaptation but early consolidation. Maintain the balance.(.

irreversible muscle damage 20% .no damage (only stretching) 10%-20% .muscle growth >20% .critical point Nerve supply Blood supply .Amount of distraction: 10%-12% .

EFFECT OF DISTRACTION ON PERIPHERAL NERVES Distraction osteogenesis may result in serious complications including peripheral nerve injury. .

constriction of medullary canal .Inferior alveolar nerve injury direct .contact with fixation devices indirect .compression by postoperative odema .intraoperative manipulation .

Adaptation of peripheral nerves to distraction peripheral nerve trunks are highly resistant to stretching 15% lengthening .early degenerative changes of myelinated nerves. swelling of schwan cells .

20% lenthening - similar changes in non myelinated nerves

20% -50% lengthening – wallerian degeneration

Regeneration of nerve fiber during consolidation

samchukov et al .No acute injury with 10 mm distraction Mild IAN changes in 10-15 % nerve fibers .

TMJ ALTERATIONS DURING DISTRACTION Different biological responses: Compression – permanent degenerative changes Adaptive joint remodeling Functional adaptation to the changing environment .

Distraction devices .

Extra oral devices Unidirectional devices:  mandibular lengthening was possible in one direction only  distraction was determined by the angle between Frankfurt horizontal plane and distraction device  cannot be adjusted after insertion .

Bidirectional devices  allows distraction in two directions as well as adjustment of angle between two arms of the device. single or double level osteotomy is possible.  .

Multidirectional devices  essential component of these devices are angulation joints and two geared rods of variable lengths. .

 in bidirectional devices the middle joint is simple hinge whereas in multidirectional devices it is multifunctional double ball joint. device can be adapted according to individual anatomic situations.  .

Semi-rigid extra oral distraction devices .

Intra oral distraction In 1996 Chin and Toth described the feasibility and potential advantages of using intra oral devices for distraction osteogenesis. .

Intraoral distraction devices       MD – DOS Device ROD custom distractor device Buried bidirectional telescopic mandibular distractor Multiaxis intra oral distractor New spiral distractor Distractor with micro hydraulic cylinder .

anterior fixation unit Spacer DU .MD – DOS DEVICE .Morrice Mommarts Started clinical application of this device in 1997 Consists of four major components PFU – posterior fixation unit AFU .distractor unit .

Depth of PFU penetration is controlled by PFU screw length and bar spacer.Posterior end of PFU is fixed in ascending ramus. .

Anterior end of DU is connected to AFU which is basically a modified five hole plate.Anterior end of PFU is connected to posterior end of DU by hinge which allows DU to rotate along vertical axis. .

there are five categories of ROD devices. with ROD device it is possible to distract first and than decompensate the teeth.ROD intra oral custom distractor device programmed along a desired vector. .

Device fabrication Distractor device consists of three components Anterior activated expander . Male attachment also have vertical slots for wire fixation. . Male attachment is soldered to the crowns. male and female attachments.

.Female part is soldered to expansion screw The intra oral attachment allows prefabrication of device presurgically and cementation of distractor device prior to osteotomy with removal of distractor screws with the female part.

. alignment tool was devolved to properly position the distractor bilat.The vector planning ROD lab.

BTMD has mediolateral offset with an adjustable screw allowing intraoperative adjustment of distractor vector and postop correction of midline occlusal discrepancies.Buried Bidirectional Telescopic Mandibular Distractor Most of the current intra oral devices are unidirectional with limited possibilities of intraoperative adjustments. .

. BTMD has also shown its use in mandibular defect reconstruction.9 to 2.BTMD is stainless steel device that can be attached to mandible with upto 1.3 mm monocortical or bicortical screws Activation is done by transmucosal approach.

should provide independent horizontal and vertical distraction -allows gradual changes between horizontal and vertical axis .Multiaxial intra oral distractor Distractor that allows distraction in more than one direction Requirement of such distractor are: .

Basic unit of such distractor: angulation gear – allows angulation change of 15’ vertical distractor is attached to posterior fixation plate by a clamp horizontal distractor is attached to anterior fixation plate .

Based on this information semi buried distractor with curvilinear vector was devolved.Spiral Distractor Several authors suggest that mandible grows in archival fashion which has been hypothesized to be along logarithmic spiral. .

Curvilinear vector is chosen by VTO .By placing the osteotomy and device at mandibular ramus the archival path of distraction would mimic the logarithmic spiral of mandibular growth.

it consists of two major parts .Distractor with Micro Hydraulic Cylinder Device is based on the concept of hydraulic pump.piston .cylinder .

Both piston and cylinder have integrated fixation plates with two holes for bone fixation using conventional 3.5 mm bicortical screws Depending on situation both incremental and continuous distraction can be applied .

Indications of Distraction Osteogenesis  Children or infants with severe retrognathia associated with a syndrome (Pierre Robin syndrome. Treacher Collins syndrome)  Unilateral hypoplasia of the mandible (Hemifacial microsomia)  Mandibular hypoplasia due to trauma and/or ankylosis of the temporomandibular joint .

 Nonsyndromic mandibular hypoplasia associated with a dental malocclusion where movement of mandible required is >10mm  Mandibular transverse deficiency associated with a dental malocclusion and dental crowding  Severe obstructive sleep apnea in patients who are morbidly obese  Shortened vertical height of the alveolar bone to receive an implant .

Contraindications of Distraction Osteogenesis  Patients who are unable or unwilling to comply with the distraction schedule  Infants < 6 months of age due to fragility of bones to place distraction devices  Inadequate bone surface to accept distraction device .

 Inadequate bone surface area to provide regeneration of bone  Caution must be exercised in patients who have undergone radiation therapy. This is because of delayed bone formation due to reduced number of stem cells  Caution must be exercised in elderly patients because of the decreased number of mesenchymal stem cells .

Treatment planning History  Records  Patient expectations  Distraction device selection  Predistraction. intradistraction and postdistraction treatment objectives  Determination of vector  Distraction protocol  .

Distraction device selection External Internal External devices Advantages : multidirectional excellent control of bone segment available in longer lengths easier to place and maintain simple to remove .

Disadvantages : skin scarring poor patient compliance Intaoral devices Advantages : no scarring better patient compliance .

Disadvantages :    difficult to place risk of injuries to nerves. vessels and tooth buds second surgical procedure is required for removal Lack of availability of multidirectional devices .

Factors for device selection • • • • desired lengthening Lengthening capabilities desired angular correction vector psychological requirements of patients .

 Ratio of amount of device activation and observed amount of distraction can go as high as 2:1 Incorporation of angular correction further decreases total amount of linear distraction  .Lengthening capabilities  To achieve desired amount of lengthening and angular correction appropriate length of distractor must be selected.

Direction of distraction Based on type of deformity and main goal of positional changes. . If only ramus or body lengthening is required unidirectional distractor would be utilized.

distractor may be placed according to the following formula: Pin placement angle = 180 – gonial angle x ramus def / total def Pin placement angle = angle between vector of distraction and mandibular plane .If simultaneous ramus and body lengthening is required.

Amount of Distraction: The amount of distraction can be determined by simply drawing a triangle two sides of which represents the amount of mandibular corpus and ramus shortening respectively. 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 . The angle between these two sides is the gonial angle and third side indicates amount of distraction.

Amount of distraction .

. If deformity correction requires mandibular lengthening in combination with gonial angle change or transverse change.In case of simultaneous maxillary defficiency amount of maxillary correction is also included in calculation. multidirectional distractor is required.

Double level osteotomy can be performed in difficult cases. .Bone ends should be separated by 10 mm before starting angular correction.

Orthodontics Predistraction orthodontics Intradistraction orthodontics Postdistracrtion orthodontics .

VECTOR PLANNING The distraction vector defines the desired direction that the distal segment must move during lengthening. .

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Despite precise planning the actual distal segment movement is difficult to predict and is affected by various forces: osteotomy design osteotomy location distracton device orientation masticatory muscle influence occlusal interferences distraction device adjustment orthodontically applied forces .

Distraction device orientation Device should be placed parallel to vector vertically horizontally obliquely .

anatomic axis of right and left sides of mandible are not parallel to each other or to desired direction of distraction. .Biomechanical effects of distraction device orientation Mandible is V shaped when viewed in transverse plane.

When viewed in sagittal plane, the inferior border of mandible is often not parallel to maxillary occlusal plane which is primary plane of reference for ant. mandibular distraction.

If distraction was placed parallel to the inferior border of the mandible, elongation occurred horizontally with opening or obliteration of gonial angle.

If distraction was placed obliquely to both ramus and body, neomandible maintained original form with preservation of gonial angle.

Laskin suggests planning distractor placement preoperatively to achieve desired results. Distractors placed parallel to the mandible with out regard to desired direction of distraction create reactive forces leading to following clinical problems: bending of distractor device loosening of fixation screws bone resorption joint compression .

The magnitude of lateral displacement tendency is proportional to amount of mandibular lengthening and mandibular arch angle. . Placement of distractor parallel to direction of distraction eliminates the tendency of lateral displacement of proximal segment.

.If the distraction cannot be placed parallel to direction of distraction and lateral displacement tendency cannot be corrected they should be compensated either by acute correction or gradually incorporating a hinge element to lengthening device.

The vertical relationship between the distal mandibular segment and maxilla during distraction is another important consideration. . An increase in lower anterior facial height occurs when the vector of distraction is oriented parallel to mandibular plane instead to the maxillary ccclusal plane.

Vertical increase in lower anterior facial height may manifest as development of anterior /posterior open bite. .

usually maxillary occlusal plane.The amount of open bite is proportional to the amount of distraction. . Increase in angle between occlusal plane vector = increased vertical deviation desired ( open bite ) and from To prevent the development of open bite distractor should be placed as possible to desired direction of distraction.

Extrinsic factors: rigidity of distractor stability of screws Intrinsic factors: soft tissue tension bone quality anatomy of mandible .But open bite can still develop due to extrinsic and intrinsic factors.

Influence of masticatory muscles Soft tissue traction due to physiologic muscle activation may contribute to distal segment instability. .

Occlusal interferences Should be corrected orthodontically Distraction device activation Depends on dimensional capability of device .

Future growth and overcorrection Skeletal age and future growth potential must be considered for distraction planning The amount of distraction required is based on careful assessment of mandible followed by compensation by growth standards or norms for particular race. . and facial skeleton maturity. sex.

• The orthodontist and the surgeon must have open communication throughout the entire planning process • They must share the same treatment objectives ..Surgical Therapy….

• Osteotomy cut Should be decided before hand with the help of imaging studies Osteotomy cut.Preoperative work up….. Where do you place it? … If the mandible is … Osteotomy cut Distrator plane • Deficient in ramus height Superior to angle of mandible on ramus Deficient in body length Anterior to angle of mandible Combination of both? Anterior and/or superior to angle of mandible? Vertical plane Horizontal plane Oblique plane?? .

Osteotomy / Corticotomty Osteotomy: Division of bone in two segments Corticotomy: Cancellous bone is kept intact or Subtotal / incomplete osteotomy .

corticotomy circumferential external External extended .

Depending on number Single Double .

to teeth Widening Midline Alveolar Horizontal segmental .Depending on type of correction Lengthening Ramus Angle B/W lateral and canine Corpus interdental Post.

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corticotomy After device placement Before device placement Distraction osteotomy Distraction protocol To start with .

External extended Preserves vascularity and tooth buds Cancellous bone is spared 6-8 mm of inner cortical bone remains intact .

downward and inward ramus distraction Required in hemifacial microsomia and other syndrome cases .Ramus osteotomy Vertical.

Angular osteotomy Downward and forward lengthening Osteotomy is prepared from distal of 2nd molar down to inferior border of mandible. 10 – 12 mm of lingual cortex is cut with bur protecting the 3rd molar .

marked and removed. Osteotomy is completed with spreader Device is placed Closure is done . Device is placed.Ridge corticotomy is done in oblique and anterior direction and than sharply turned posterior to angle of mandible.

vertically upto 3mm of inferior alveolar canal Outer cortex is than sectioned .Corpus osteotomy Horizontal and forward lengthening Inferior border channel retractor is placed between 2nd and 3rd molar. Mandible is than transected through both buccal and lingual cortex at inferior border.

Protecting the lingual periosteum saw is placed upside down and osteotomy is carried through alveolar crest. sup. 6 mm medial bone is kept intact . Inf. to 3mm superior to canal.

Device is placed Closure is done with small aperture at the top of incision to facilitate vertically placed chisel . which is placed to give final cut followed by complete closure .

Mandibular widening Complete osteotomy is done midline between central incisors below the roots of incisors. Alveolar bone is than sectioned with bur taking care of teeth and gingiva .

If teeth are very close the alveolar bone and gingiva.lingual cortex is green fractured with expansion forceps device. .

the patient should be seen every 2-3 days to monitor the advancement and to intercept any potential occlusal discrepancies During the consolidation phase.Postoperative details What should the surgeon watch for after the placement of distractor ? During the distraction phase. the patient should be seen on a weekly basis to monitor healing and ossification of the regenerate .

a slight over correction of the mandibular midline is recommended to overcome the deficient soft tissue envelope . the patient should be distracted until a slight class III dental occlusion exists (edge-edge incisal relationship) In a unilateral expansion.In bilateral expansion of the mandible.

COMPLICATIONS A complication is an unexpected deviation from the treatment plan that. with out appropriate correction will lead to worsening of existing. development of a new. or recurrence of the initial pathologic process .

Mistake Mistake is an inattentive action that results in a deviation of the course of treatment. thereby leading to the development of a complication .

Potential mistakes Iatrogenic Patient related .

Potential complications .

-inappropriate size and strength of device -inadequate osteotomy level -inadequate device orientation -inadequate hinge placement -inaccurate placement of device -comminuted osteotomy .Axial deviation Axial deviation of distracted segment can result from various mistakes.

Correction of axial deviation begins with elimination of main cause of this deviation. -replacement of distracter device -repositioning hinge axis -reorientation -additional surgery .

Soft tissue overstretching Blood vessels rare least tolerant to compressive forces lead to ischemia .

more with extra oral devices .Adjacent joints degenerative changes Skin scaring and necrosis Infection incidence is 5-30%.

Distraction vs Osteotomy Distraction Need for bone grafting Osteotomy Not necessary even for Necessary for defects defects > 20 mm >10 mm Control over movement On infants and children 3 Dimensional Can be done 2 Dimensional Think about permanent teeth and sufficiency of bone Risk of causing Risk of causing Not Possible Relatively inexpensive Distortion and loading of the TMJ Damage to the inferior alveolar nerve Cost Does not cause Does not cause Increasing ramus height Possible Expensive (distractors and equipment ) Time Takes time Quick Fix Method .

will always have a place. such as the bilateral sagittal split osteotomy.Distraction vs osteotomies The argument contnues…. distraction osteogenesis allows a surgeon to treat patients who are unable or unwilling to undergo a traditional osteotomy . While traditional mandibular osteotomies.

Distraction osteogenesis is a highly predictable and reliable method of increasing the bone in a deficient mandible

With technology advancements, the distraction devices become smaller and more sophisticated making distraction movements more precise

One of the current controversies involves using distraction osteogenesis instead of the traditional bilateral sagittal split osteotomy Some authors have gone so far as to state that the bilateral sagittal split osteotomy is an obsolete procedure with no place in current practice

In reality, traditional mandibular osteotomies will always have a place; however, distraction osteogenesis provides the surgeon with another option in treating a wide variety of mandibular deficiencies

Alexander M. . Cope. 4. Oral and maxillofacial Wardbooth.References 1. Oral and maxillofacial surgery – Fonceca. Craniofacial distraction osteogenesis – Mikhail L. Jason B. 3. Samchukov. Cherkashin Distraction of the craniofacial skeleton – Joseph G. McCarthy. surgery – Peter 2.