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PubMed2003

Mandibular symphyseal distraction osteogenesis: diagnosis and treatment planning considerations.

Treatment planning decisions in the transverse dimension have historically been based on the presenting mandibular arch width and form. Distraction osteogenesis (DO), originally developed by Russian orthopedic surgeon Ilizarov, has produced significant results in limb lengthening. Mandibular symphyseal DO was introduced by Guerrero, providing a new paradigm for patients whose treatment alternatives and results were previously limited. Orthodontic and surgical techniques and principles will be shown using completed and current cases.

Decision Making↗
PubMed2005

Using the finite element method to model the biomechanics of the asymmetric mandible before, during and after skeletal correction by distraction osteogenesis.

An approach was developed to evaluate the load transfer mechanism in the temporomandibular joint (TMJ) area before, during and after mandibular ramus elongation by distraction osteogenesis (DO). In a concerted approach using computer tomography, magnetic resonance imaging (MRI), and finite element analysis, three-dimensional numerical models based on a young male patient, with a dento-facial deformity were generated. The magnitude and direction of the muscle forces acting on the mandible were assessed using both values derived from the muscles volume and cross-section as retrieved from the MRI-scan data-sets and taken from the literature. The resistance of the soft tissue envelope towards elongation during the DO-phase was also included. The finite element analyses showed that before skeletal correction by DO the load transfer was asymmetrical with high peak stresses in the affected joint. Following ramus elongation a more symmetrical loading in TMJs was predicted. The reaction forces in the TMJs during DO were low.

Arthritis, Juvenile↗
PubMed2005

The application of alveolar distraction osteogenesis following nonresorbable hydroxyapatite grafting in the anterior maxilla: a clinical report.

Distraction osteogenesis is a method of increasing bone length through the application of slow, controlled force on bone segments where periosteum and medullary blood supply are maintained. Recently, the procedure has been adapted to alveolar augmentation prior to prosthodontic rehabilitation. This report describes the use of alveolar distraction in the anterior maxilla and presents, to the authors' knowledge, the first reported successful application of the technique following nonresorbable hydroxyapatite grafting.

Absorbable Implants↗
PubMed2001

Intraoral distraction osteogenesis of the mandible in hemifacial microsomia.

PURPOSE: Lengthening of the mandible by distraction osteogenesis is the preferred method for treatment of hemifacial microsomia in children. Use of an intraoral distraction technique and horizontal oblique ramus osteotomy in such patients is presented. PATIENTS AND METHODS: Mandibular ramus lengthening was performed in 11 patients aged 6 to 12 years with hemifacial microsomia. During the age of mixed dentition in hemifacial microsomia patients with a hypoplastic mandible, the unerupted molars buds are located high in the retromolar region and are in danger of being damaged by the osteotomy. Therefore, an intraoral approach exposing the mandibular ramus and angle was performed, and a horizontal oblique ramus osteotomy was made, preserving the inferior alveolar nerve. An intraoral device was placed along the ramus, and distraction was started on the third postoperative day at the rate of 1 mm/d and continued for 2 to 3 weeks or as long as necessary. The device was maintained for retention an additional 6 weeks and was then removed. RESULTS: Clinically, the face became more symmetric. The postdistraction posteroanterior cephalometric radiographs demonstrated elongation of the affected ramus and improvement in facial symmetry. CONCLUSIONS: The advantages of this method are that it allows device placement along the ramus, permitting the ramus elongation necessary in treatment of hemifacial microsomia, that it prevents damage to the tooth buds which, during the age of mixed dentition, are in a higher position in the retromolar area, and that it prevents injury of the inferior alveolar nerve.

Cephalometry↗
PubMed2004

Longitudinal dento-skeletal changes in UCLP patients following maxillary distraction osteogenesis using RED system.

Longitudinal dento-skeletal changes in unilateral cleft lip and palate (UCLP) patients following maxillary distraction osteogenesis using the rigid external distraction device (RED) were analyzed. Twelve Japanese non-syndromic UCLP patients who underwent maxillary distraction at the mean age of 16.4 years were used as subjects. Serial sets of lateral cephalograms, taken at 4 stages: 1) before osteotomy, 2) immediately after distraction, 3) 6 months and 4) 12 months post-osteotomy, were analyzed. Statistical analyses, including a paired t test, Pearson correlation analysis and stepwise linear regression analysis, were performed to distill characteristic dento-skeletal changes. In accordance with maxillary advancement, significant amounts of up-forward movement of the nasal bone, mandibular rotation and maxillary dental changes were observed. Maxillary dental changes were significantly related to the amount of mandibular rotation and force system of maxillary traction. Significant dento-skeletal relapse was found to occur during the 0-to-6-month follow-up period, but not in the 6-to-12-month follow-up period. Maxillary relapse was significantly related to the amount of maxillary advancement and severity of pre-surgical maxillary hypoplasia, while mandibular relapse was significantly related to maxillary dento-skeletal relapse. Successful clinical application of this procedure therefore requires consideration of both the surrounding dento-skeletal changes and the traction force system.

Adolescent↗
PubMed2002

[Bone distraction osteogenesis].

Bone osteogenesis has been used by many surgeons to compensate dissymmetry due to congenital malformations, diseases or traumas. Bone distraction is the process of generating new bone in a gap between two bone segments in response to the application of graduated tensile stress across the bone gap. Different types of distraction are actually proposed to be an alternative to facial osteotomies or bone grafting techniques. Distraction can be unilateral, bilateral and correct the deficiencies in one, two or three dimensions. The advantages of the distraction osteogenesis are the possibilities to obtain bone lengthening together with simultaneous expansion of the functional soft tissue matrix including skin, muscles, nerves, cartilage, blood vessels and periosteum. Distractors are internal or external devices made of pins or miniplates fixed on the bone and connected by lengthening--screw--systems allowing elongation.

Adolescent↗
PubMed2006

Mandibular distraction osteogenesis with a small semiburied device in neonates: report of 2 cases.

Distraction osteogenesis has recently assumed an important role in the correction of craniofacial anomalies, particularly for the treatment of potentially life-threatening, deformity-associated upper airway obstruction and respiratory dysfunction in neonates. Such deformities include Treacher Collins syndrome, Goldenhar 's syndrome, Nager's syndrome, temporomandibular joint ankylosis, and Pierre Robin sequence. These conditions frequently require a tracheostomy to maintain airway patency. We report our experience with using mandibular distraction as a valid alternative to tracheostomy. Minimally invasive surgery is possible with small semiburied devices.

Airway Obstruction↗
PubMed2005

Maxillofacial intraoral distraction osteogenesis followed by elastic traction in cleft maxillary deformity.

We present a case of severe maxillary hypoplasia in a 16 years old cleft patient treated by distraction osteogenesis maxillary advancement. Initial evaluation showed vertical and antero-posterior maxillary deficiencies, and a Class III malocclusion. Two intraoral distractors (Zurich Pediatric Maxillary Distractor, KLS Martin, Tuttlingen, Germany) were placed in a high Le Fort I osteotomy. An initial advancement of 11 mm was obtained, but the resulting occlusion was unsatisfactory (end-to-end occlusion). The consolidation period was reduced to 3 weeks to allow the mechanical manipulation of the newly formed bone with Class III elastics. An additional advancement of 3 mm, caused by elastic orthodontic traction produced both normal skeletal relationship and satisfactory occlusion. This observation shows that it is possible to carry on a skeletal maxillary displacement by interdental elastics before the complete fusion of the callus. After 12 months of postoperative follow-up no osseous relapse could be detected and the occlusal result was stable.

Adolescent↗
PubMed2002

IGF-I, TGF-beta, and BMP-4 are expressed during distraction osteogenesis of the pig mandible.

The mechanisms that regulate bone formation during distraction osteogenesis (DO) are not completely understood. Our hypothesis is that local cytokines that stimulate osteoblast activity are potential regulators of this process. The purpose of this study was to determine gene expression of insulin-like growth factor I (IGF-I), transforming growth factor-beta (TGF-beta), and bone morphogenetic protein 4 (BMP-4) in distracted wounds. A semiburied, rigid distraction device was placed across an osteotomy at the right mandibular angle in 9 Yucatan minipigs. Distraction was begun immediately at a rate of 1 mm/day. The animals were sacrificed after 4 and 7 days of distraction, and after 7 days of distraction plus 4 days of neutral fixation. Excised wound tissues were processed for histologic and gene expression analyses. Competitive reverse-transcription polymerase chain reaction (RT-PCR) assays were developed and validated for porcine genes. Histologic analysis showed membranous ossification within the DO wound. Gene expression of IGF-I, TGF-beta and BMP-4 was detected during distraction and neutral fixation. These results show that gene expression analyses can be performed in a large animal model of mandibular DO. As the pig mandible closely resembles that of the human in morphology and physiology, this is an important step toward characterization of the early molecular events in the DO wound.

Animals↗
PubMed2006

Effect of distraction rates on expression of bone morphogenetic proteins in rabbit mandibular distraction osteogenesis.

BACKGROUND: The expression of bone morphogenetic proteins can be regarded as an indicator for biological interaction in distraction osteogenesis. It was hypothesized that different distraction rates may produce different patterns of BMP expression. MATERIAL AND METHODS: This study compared the expression of BMP-2, -4 and -7 at routine (0.9mm once daily) and rapid (2.7mm once daily) distraction rates using the rabbit mandibular lengthening model. Mandibular samples were harvested at days 1, 7 and 14 of consolidation. RESULTS: The expression of BMP-2 and BMP-4 was found throughout the experiment, their expression intensity and location being essentially similar, whereas BMP-7 had not been expressed. Expression of BMP-2 and -4 was more intense at the routine distraction rate than at the rapid distraction rate. CONCLUSIONS: BMP-7 had no expression during the consolidation period of mandibular distraction. The change in the mechanical environment created by different distraction rates led to different expression of BMP-2 and -4. In the early consolidation stage the biological environment for bone formation created by distraction at a routine rate was superior to that created by the rapid distraction rate.

Animals↗
PubMed1999

Long-term effect of mandibular midline distraction osteogenesis on the status of the temporomandibular joint, teeth, periodontal structures, and neurosensory function.

PURPOSE: This study retrospectively evaluated the long-term effects of transverse symphyseal distraction osteogenesis (DO) on the temporomandibular joint (TMJ) symptoms, periodontal health, tooth vitality, and nerve injury after surgery. PATIENTS AND METHODS: Twenty-three patients were treated with symphyseal DO during a 4-year period. Fifteen patients were available for follow-up from 7 to 45 months postoperatively (ave, 24.5 months). The patients were clinically evaluated for TMJ symptoms, periodontal pocket formation, tooth vitality and mobility, crestal bone loss, and attached gingival tissue changes. Radiographs of the mandibular anterior teeth were used to evaluate for periodontal bone loss, periapical lesions, or widening of the periodontal ligament (PDL). RESULTS: Preoperatively, 47% of the patients had TMJ symptoms. No patient had symptom worsening or developed new symptoms postoperatively. Five patients' TMJ symptoms improved, and 3 experienced complete resolution of symptoms. No periodontal bone loss or soft tissue recession were evident. Tooth vitality was maintained in 13 patients. Two patients developed Class II mobility of 1 mandibular central incisor, 1 patient had tooth pain and a widened PDL adjacent to the osteotomy/corticotomy site, and 1 patient experienced mental nerve paresthesia. CONCLUSIONS: DO can be used to treat transverse discrepancies of the mandible with limited morbidity.

Adolescent↗
PubMed2005

The determinants of successful distraction osteogenesis of the mandible in hemifacial microsomia from longitudinal results.

The purpose of this study was to investigate sagittal, vertical, asymmetric skeletal characteristics that could determine successful distraction osteogenesis (DO) of the mandible in patients with hemifacial microsomia using longitudinal follow-up data. Lateral and posteroanterior cephalometric radiographs before DO (T0), after DO (T1), and after retention (T2) were analyzed to investigate initial skeletal characteristics, DO effect, and retention. From the measurements at T2, patients were classified into group 1 (good retention results, N = 10) and group 2 (poor results, N = 9). Sagittal, vertical, dental, and asymmetric variables were measured. The differences at each stage and during T0-T1 and T1-T2 between two groups were compared by Mann-Whitney u test, Wilcoxon signed rank test and ANOVA test. Pruzansky type significantly influenced the success or failure of DO. At T0, group 2 showed more retrognathic mandible, smaller ramus height, larger gonial angle, more inward ramus inclination of the affected side, and more chin point deviation to the affected side than did group 1. The major effects of DO on group 1 were lengthening of the ramus height, forward positioning of the mandible, increase of gonial angle, counterclockwise rotation caused by a decrease of the articular angle, increase of ramus inclination of the affected side, and improvement of occlusal canting and chin point deviation. However, by DO, group 2 showed clockwise rotation of the mandible, and less increase of the ramus height than did group 1. After retention, group 2 showed counterclockwise rotation of the mandible and little growth of the ramus height. Group 1 showed reverse tendency. These factors could contribute to the difference in long-term results between two groups.

Analysis of Variance↗
PubMed2006

Experimental studies on the effect of osteotomy technique on the bone regeneration in distraction osteogenesis.

The objective of the experiment was to study the effect of osteotomy technique on the course of bone regeneration in distraction osteogenesis in sheep. Thirty five merino sheep were divided into 5 groups of 7 sheep each, depending on the osteotomy technique: subcutaneous corticotomy, open corticotomy, Cattaneo corticotomy, open osteotomy and osteoclasia. Formation of regenerate and its remodeling was assessed, based on roentgenograms and morphological examination (bone sections, histological evaluation, SEM, superficial X-ray analysis). Irrespective from the osteotomy technique applied, in all experimental groups, regenerates filling the distraction gap were obtained. Analysis of bone sections and histological slides indicated the most advanced osteogenesis processes in the osteoclasia group. SEM examination and X-ray microanalysis confirmed not only the presence of mature bone tissue structures in this group, but also showed a mineralization close to that of a healthy bone. Osteogenesis was the slowest in the group of subcutaneous corticotomy. The observed histological picture and analysis of elemental composition indicate a normal course of distraction osteogenesis in this group, but its consecutive phases proceed with a certain delay, compared to the remaining groups. With a good deal of caution, it can be assumed that the delay of osteogenesis in the group of subcutaneous corticotomy in the 14th post-operative week was ca. 3 weeks compared to the osteoclasia group. In all experimental groups, few cartilaginous nodules were observed in regenerates 5 weeks and, in few cases, 9 weeks old. Ossification in such places was indirect, cartilage-based. In the remaining regions direct, membrane-based ossification prevailed. Direct apposition bone lamellae on islands of fibrous bone tissue was observed in regenerates aged 9 and 14 weeks, especially in periosteal regions. The intensity and rate of formation of new bone tissue varied between the experimental groups, based on roentgenological analysis and histological evaluation. Complex morphological studies on the course of regeneration in sheep showed the most advanced remodeling and mineralization of bone tissue in animals subject to osteoclasia.

Animals↗
PubMed2001

Intravenous pamidronate reduces osteoporosis and improves formation of the regenerate during distraction osteogenesis. A study in immature rabbits.

We examined the effect on bone mineral density (BMD) of a single dose of 3 mg/kg of the bisphosphonate, pamidronate (Novartis) in distraction osteogenesis in immature rabbits. Seventeen rabbits (9 control, 8 given pamidronate) were examined by dual-energy x-ray absorptiometry. There was a significant increase in the BMD in the pamidronate group compared with the control animals. The mean areal BMD (g/cm2) in the bone proximal and distal to the regenerate was increased by 40% and 39%, respectively, compared with the control group (p < 0.05). The BMD of the regenerate bone was increased by a mean of 43% (p < 0.05). There was an increase of 22% in the mean area of regenerate formed in the pamidronate group (p < 0.05). Histological examination of bone in nine rabbits (5 control, 4 pamidronate) showed an increase in osteoblastic rimming and mineralisation of the regenerate, increased formation of bone around the pin sites and an increase in the cortical width of the bone adjacent to the regenerate in the rabbits given pamidronate. Pamidronate had a markedly positive effect. It reduced the disuse osteoporosis normally associated with lengthening using an external fixator and increased the amount and density of the regenerate bone. Further study is required to examine the mechanical properties of the regenerate after the administration of pamidronate.

Animals↗
PubMed2005

Expression of bone morphogenetic protein-2 and proliferating cell nuclear antigen during distraction osteogenesis in the mandible in rabbits.

We examined the expression of bone morphogenetic protein-2 (BMP-2) and proliferating cell nuclear antigen (PCNA) during distraction osteogenesis in the mandible in rabbits. Twenty-four rabbits each had an osteotomy of the left mandibular body, and distraction devices were fixed. The bone was distracted at a rate of 1mm/day for 10 days. Four rabbits were killed at each of 1, 3, 7, 14, and 28 days after completion of distraction, and the mandibles examined radiographically, histologically, and immunohistochemically. Four rabbits that had not been operated on served as controls. Immunohistochemical analysis showed that BMP-2 and PCNA both appeared initially at the edge of the osteogenesis, but tended to disappear after 14 days. After 1, 3, 7, and 14 days after distraction, the ratio of stained cells was significantly higher than in the control group (p<0.05), during the period that active bone formation was shown radiographically and histologically. These results suggest that BMP-2 plays an important part in the induction of bone formation during distraction osteogenesis.

Animals↗
PubMed1998

Maxillary distraction osteogenesis in Pfeiffer's syndrome: urgent ocular protection by gradual midfacial skeletal advancement.

Distraction osteogenesis is increasingly recognised as a potentially useful technique to achieve the co-ordinated augmentation of craniofacial skeletal and soft tissue. A case is presented where bilateral maxillary distraction was successfully used to advance the midface in the treatment of recurrent ocular dislocation, in a 10-month-old boy with Pfeiffer's syndrome.

Acrocephalosyndactylia↗
PubMed2006

Distraction osteogenesis in irradiated rabbit mandibles with adjunctive hyperbaric oxygen therapy.

PURPOSE: The purpose of this study was to evaluate the effect of hyperbaric oxygen therapy on bone regeneration during distraction of irradiated rabbit mandibles. MATERIALS AND METHODS: Twenty New Zealand white rabbits were randomly sub-divided into 4 groups. Group 1 served as control, group 2 received preoperative radiation therapy, group 3 received pre- and postoperative hyperbaric oxygen (HBO) therapy, and group 4 received preoperative radiation therapy and pre- and postoperative HBO therapy. All rabbits underwent a corticotomy of the left body of the mandible after placement of a distraction device. Distraction, at a rate of 1 mm/day and a rhythm of 1 turn/day, began after a 3-day latency period for 14 days. Thirty days after completion of the distraction protocol, the animals were euthanized, and histomorphometric and radiographic data of the distraction segments were obtained. RESULTS: Histomorphometric analysis of new bone fill was greatest in the non-irradiated groups compared to groups receiving radiation therapy, regardless of HBO therapy (P = .03). Pre-corticotomy bone density measurements showed a significant increase in bone density over time (P = .0007). This resulted in a significant relationship between HBO therapy, radiation therapy, and time (P = .0050). CONCLUSIONS: The results of the study support the use of HBO therapy during distraction osteogenesis. Any additional therapeutic benefit of HBO therapy in irradiated bone would require additional investigation.

Analysis of Variance↗
PubMed1999

Recombinant growth hormone accelerates bone regenerate consolidation in distraction osteogenesis.

The purpose of the present study was to prove whether homologous GH has a stimulating effect on bone healing. Therefore, left tibiae of 30 micropigs were osteomized and distracted over an external fixator at the rate of 2 mm/day on each of 10 consecutive days. Animals were killed after a healing period of another 10 days. The treatment group received 100 microg of recombinant porcine growth hormone (rpGH) per kilogram of body weight per day. Serial torsional nondestructive biomechanical tests were performed in vivo using a newly developed measurement device. After killing, destructive torsional strength testing of the sites of distraction was performed. To determine the endocrine response to the administration of rpGH, serum levels of insulin-like growth factor-I (IGF-I) were determined. Nondestructive in vivo testing showed that torsional stiffness of the regenerate was significantly higher in the treatment group than in the control group. Final regenerate torsional failure load was 131% higher and ultimate torsional stiffness was 231% higher in the treatment group than in the control group. The mean serum level of IGF-I increased to 440% of preoperative basal level in the treatment group and remained unchanged in the control group. Our data indicate that systemic administration of recombinant homologous growth hormone greatly accelerates ossification of bone regenerate in distraction osteogenesis.

Animals↗