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PubMed2000

Distraction osteogenesis for mandibular advancement.

The purpose of this study was to investigate the possibilities of distraction osteogenesis to correct mandibular hypoplasia. Fourteen young patients (mean age 14.1 years) with a proven resistance to initial, functional orthodontic therapy, were treated by means of bilateral intraoral distractors. The corticotomy was performed in the region of the third molar. The latency time was six days and the stabilization period six weeks. In all cases the planned lengthening of the mandible and class 1 occlusion were achieved. Seven patients required additional elastic band traction to close a mild open-bite directly after active distraction. In the first seven patients, insufficient mobilization at the site of the corticotomy had resulted in a broken distraction rod in two patients and incomplete distraction of the lingual cortex in one patient. Adequate mobilization at the site of the corticotomy prevented these problems in later cases. No permanent sensory disturbances were seen. Twelve patients finished their orthodontic treatment within six months after distraction.

Adolescent↗
PubMed1997

Effect of the distraction rate on the activity of the osteoblast lineage in distraction osteogenesis of rat's tibia. Immunostaining study of the proliferating cell nuclear antigen, osteocalcin, and transglutaminase C.

The purpose of this study was to investigate kinetics of the osteoblast lineage in the periosteum and endosteum according to different distraction rates in distraction osteogenesis of rat's tibia. An osteotomy was performed on 144 rats at the proximal diaphysis of the left tibia. The lengthening process was started after a latency period of 3 days, with varying distraction rates of 0.25 mm (group I), 0.5 mm (group II), 0.75 mm (group III), 1.0 mm (group IV) and proceeded until a 3.5 mm length gain was achieved. The animals that had an osteotomy alone, without lengthening, served as a control (group V). Immunohistochemical staining of proliferating cell nuclear antigen (PCNA), osteocalcin, and transglutaminase C (TGase C) were done on the four animals in each group sacrificed at post-distraction days 1, 3, 5, 7, 14, and 28 in order to observe the temporal changes among the experimental and control groups. Also, in order to compare the staining rates at a given length gain among the groups, animals in each group were additionally sacrificed 2 days post-distraction in group II; 2 and 4 days in group III; and 1.5, 2 and 2.5 days in group IV. The results of the expression rates of PCNA, osteocalcin, and TGase C in each group were analyzed quantitatively. The immunohistochemical study on callotasis of rat's tibia revealed that the osteoblast lineage in the periosteum is more activated than that in the endosteum for proliferation and differentiation by distraction, suggesting that the periosteum plays a more important role in neoosteogenesis in the distraction gap. Daily distraction rates ranging from 0.25 mm to 0.75 mm in two increments is appropriate for successful distraction osteogenesis of rat's tibia, but the rate of 0.25 mm a day is significantly better than that of 0.75 mm as was made evident in the immunohistochemical observations.

Animals↗
PubMed2006

Management of nonunion with distraction osteogenesis.

Nonunions of long bone fractures represent a clinical entity that is commonly perpetuated by a high velocity injury. There are both bony and soft tissue factors responsible for the nonunion. This paper is focused on the reported clinical and radiographic outcomes whenever treatment protocols pertaining to distraction osteogenesis are implemented.

Female↗
PubMed2003

Ultrasound: assessment of the distraction osteogenesis wound in patients undergoing mandibular lengthening.

PURPOSE: Common methods of assessment of the clinical distraction osteogenesis (DO) wound consist of serial physical examinations, plain radiographs, and computed tomography (CT). Ultrasound (US) is an inexpensive and efficient method of imaging that provides detailed assessment of bone formation across a defect. It has proved to be useful for the evaluation of long bone DO healing. The purpose of this study was to determine the efficacy of US for evaluation of bone formation in the mandibular distraction wound. PATIENTS AND METHODS: Ten patients underwent mandibular expansion (18 sides) with semiburied, unidirectional distraction devices. The wounds were assessed with plain radiographs and US immediately before device removal. Estimates of bone formation, using a semiquantitative bone fill score, were made for plain radiographs and US. US beam penetration depth, in millimeters, was also measured. During removal of the distraction device, bone formation and mandibular stability were assessed by the surgeon and graded on a semiquantitative scale. RESULTS: US bone fill scores correlated with intraoperative assessment of bone formation and stability (r = 0.758, P =.0018) at all 18 mandibular sites. Plain radiographic scores also correlated with bone formation (r = 0.592). However, in 14 of 18 sides, plain radiographs underestimated bone formation compared with US and operative findings. CONCLUSION: The results of this study indicate that US is an accurate noninvasive technique that may prove to be useful in assessing the mandibular DO regenerate in patients.

Adolescent↗
PubMed1998

[Distraction osteogenesis for the correction of severe unilateral posterior lockbite: preliminary report].

The aim of this study was to promote an effective approach, which was surgically-assisted buccal mandibular corticotomy in the lockbite side to rapidly expand mandibular arch to correct unilateral posterior lockbite using the principle of the distraction osteogenesis. The typical subject was a 16-year-old patient with unilateral posterior lockbite. The orthodontic treatment had been done before the surgery. After the surgery, reciprocal elastic traction between upper and lower arch were used immediately in the lockbite side. The results demonstrated that unilateral posterior lockbite could be effectively corrected with unilateral buccal mandibular corticotomy and rapid mandibular expansion, and the stability appeared satisfactory. This article also discussed the indications of the approach and processes of treatment.

Adolescent↗
PubMed2005

Long-term skeletal effects of mandibular symphyseal distraction osteogenesis. An implant study.

The purpose of this study was to investigate the long-term skeletal effects of mandibular symphyseal distraction osteogenesis (MSDO) with a tooth- and bone-borne distraction device, analysed using the metallic implant method. The study sample comprised 20 patients between 15.8 and 25 years of age, with a mean age of 20.01 +/- 2.25 years at the start of treatment. In 12 subjects, titanium implants were inserted in the mandible to analyse mandibular skeletal changes in the short and long term. A custom-made intraoral, tooth- and bone-borne distractor was designed and used. After a latency period of 7 days, the distractor was activated twice daily, by a total amount of 1 mm. Postero-anterior (PA) cephalograms were obtained at the start of distraction and at the end of consolidation (94.95 +/- 5.79 days after surgery) and follow-up periods (21.5 +/- 4.6 months after consolidation). The data were analysed statistically using paired t-tests. The mean amount of screw activation was 8.10 +/- 1.68 mm. The inter-symphyseal and inter-molar implant distances and the bimolar width significantly increased during the consolidation period (P < 0.001) and were maintained at the end of the follow-up. On the other hand, the bicondylar width was markedly decreased (P < 0.05), while no significant skeletal changes were observed in bigonion and biantigonion widths, inter-ramal implant distance, or inter-ramal and implant angles at the end of the consolidation period. The long-term findings of this study indicate that MSDO provides an efficient and stable non-extraction treatment alternative, mainly by increasing the anterior mandibular skeletal and dental arches.

Adolescent↗
PubMed2004

Distraction osteogenesis (callotasis) for pelvic closure in bladder exstrophy.

The success of urogenital reconstruction in bladder exstrophy is dependent on how successfully the pelvic ring can be closed. In patients with this disorder, the pubic bones are short and separated. A two-component plate-rod combination was designed to widen the pelvic ring using distraction osteogenesis (callotasis). After a middiagonal iliac osteotomy, two components of the implant are connected with two bolts passing through the iliac bone. After 10 days, the rods outside the skin are approximated gradually. When the pubic bones get close, they are fixed by heavy nonabsorbable sutures. The current study included 14 patients who were operated on between 1990 and 1996. The mean followup was 6 years. No neurologic or vascular complications developed. Successful tension-free closure of the abdominal wall was achieved in all but one patient. Urogenital reconstruction was done in the second stage. In all but one patient, the bladder was closed in one stage of urogenital reconstruction. In one patient (7%), a deep infection developed for which the patient needed early implant removal resulting in failure of the urogenital reconstruction. The described method addresses the pathoanatomy of the pelvic ring. The diameter of the pelvic ring can be widened and the pubic bones can be approximated without a significant increase in tension.

Abnormalities, Multiple↗
PubMed2005

Immunohistochemical localization of bone morphogenetic protein-signaling Smads during long-bone distraction osteogenesis.

In this study we investigated the expression of bone morphogenetic protein (BMP)-signaling Smads in distraction osteogenesis (DO). Osteotomy of the right tibia was performed in 14 skeletally mature white New Zealand male rabbits. Lengthening was started 1 week later at a rate of 0.5 mm/12 hr and was maintained for 3 weeks. Expression of Smad proteins 1, 4, 5, 6, 7, and 8 and Smad ubiquitin regulatory factors (Smurfs) 1 and 2 was evaluated in the distracted zone using immunohistochemistry. Expression of receptor-regulated Smads (R-Smads) 1, 5, and 8 showed a significant increase during the distraction phase, followed by a gradual decrease during the consolidation phase. Smad 4 showed significant expression during both distraction and the beginning of the consolidation phase. Smad 6 and Smad 7 were highly expressed during the consolidation phase. Staining for both Smurfs 1 and 2 was maximal at the end of the distraction period. Staining for all proteins was most intense in chondrocyte and fibroblast-like cells. Expression pattern of R-Smads correlated with our previously reported expression pattern of BMPs 2, 4, and 7 and their receptors. These results therefore suggest a role for the whole BMP signaling pathway including the Smad proteins in DO.

Animals↗
PubMed2004

Monobloc distraction osteogenesis in pediatric patients with severe syndromal craniosynostosis.

The management of the hypoplastic midface in syndromic craniosynostosis remains a great challenge. Frequently, patients have to be operated on numerous times to achieve a satisfactory end result, partially because of the limited skeletal advancement possible when using traditional surgical techniques. During the last decade, however, methods for gradual midfacial distraction have been presented, whereby greater advancements can be obtained. We present four children aged 17 months to 15 years with severe syndromal craniosynostosis in need of midface advancements because of severe respiratory obstruction or severe exophthalmos. These patients were complex cases with several previous craniofacial surgeries (mean of three times, range of two to six times) that yielded insufficient skeletal advancements. They were operated on with gradual monobloc advancements using the Modular Internal Distraction System. The mean length of operations was 370 minutes (range: 240-455 minutes), and the mean amount of perioperative blood transfusion needed was 1,300 ml (range: 280-2,700 ml) or 66.9 ml/kg (range: 31.1-94.9 ml/kg). The patient with the greatest number of previous operations also had the longest operation time as well as the most blood loss. The average midface advancement obtained was 25 mm (range: 20-30 mm), resulting in cessation or a significant decrease of preoperative respiratory problems, reduced exophthalmos, and improved facial profile. Apart from a local infection in one patient with a connective tissue disorder and several previous wound infections, no major postoperative complications were recorded. Distraction osteogenesis has become a versatile and safe technique that allows for large advancements of the midface.

Adolescent↗
PubMed2001

Changes in speech following maxillary distraction osteogenesis.

OBJECTIVE: The purpose of this study was to describe changes in articulation and velopharyngeal function following maxillary distraction osteogenesis. DESIGN: This is a descriptive, post hoc clinical report comparing the performance of patients before and after maxillary distraction. The independent variable was maxillary distraction while the dependent variables were resonance, articulation errors, and velopharyngeal function. SETTING: The data were collected at a tertiary health care center in Chicago. PATIENTS: The data from pre- and postoperative evaluations of 18 maxillary distraction patients were used. OUTCOME MEASURES: The outcome measures were severity of hypernasality and hyponasality, velopharyngeal orifice size as estimated using the pressure-flow technique, and number and type of articulation errors. RESULTS: At the long-term follow-up, 16.7% exhibited a significant increase in hypernasality. Seventy-five percent of patients with preoperative hyponasality experienced improved nasal resonance. Articulation improved in 67% of patients by the 1-year follow-up. CONCLUSIONS: In a predominately cleft palate population, the risk for velopharyngeal insufficiency following maxillary distraction is similar to the risk observed in Le Fort I maxillary advancement. Patients being considered for maxillary distraction surgery should receive pre- and postoperative speech evaluations and be counseled about risks for changes in their speech.

Adolescent↗
PubMed2004

A preliminary morphologic classification of the alveolar ridge after distraction osteogenesis.

PURPOSE: We sought to develop and evaluate a preliminary morphologic classification of the alveolar ridge after distraction osteogenesis. MATERIALS AND METHODS: Twelve patients (7 women and 5 men; mean age, 42.6 years; age range, 30 to 57 years) underwent a total of 17 alveolar ridge distractions before the placement of a total of 44 dental implants. Ridge bone morphology was evaluated and categorized at implant placement, with subsequent evaluation of the frequency and type of complications in each category. RESULTS: Four morphologic categories were identified, as follows. Category I consisted of wide alveolar rim and no bone defects; 7 (41.2%) of the 17 ridges were assigned to this category, and a total of 22 implants were placed with no complications. Category II consisted of wide alveolar rim, lateral bone surface concavity; 4 (24%) of the 17 ridges were assigned to this category, and a total of 8 implants were placed, with fenestration defects being the most frequent complication (2 of 8 implants [25%]). Category III consisted of narrow alveolar rim, lateral bone surface concavity; 5 (29.4%) of the 17 ridges were assigned to this category, and a total of 13 implants were placed, with dehiscence defects being the most frequent complication (4 of 13 implants [31%]). Category IV consisted of distraction transport segment forming a bridge, without bone formed beneath, necessitating guided bone regeneration; 1 (6%) of the 17 ridges was assigned to this category, and following bone regeneration 1 implant was placed, without complications. Subcategory D consisted of lingual deviation of the distraction axis, occurring in any of categories I to IV, and when severe requiring corrective osteotomy to free and reposition the transport segment and neoformed bone; 4 (24%) of the 17 ridges were assigned to this subcategory (ie, to subcategory ID, IID, IIID, or IVD); in 1 case, the deviation was severe, requiring corrective osteotomy; in this case 3 implants were placed, without complications. CONCLUSION: This preliminary morphologic classification of the postdistraction alveolar ridge effectively categorizes the variation observed in our patients and in our experience provides a useful basis for decision-making regarding implant placement. However, further studies are required to confirm the generality of this classification and incidences of complications in each category.

Adult↗
PubMed1999

Digital radiography. A predictor of regenerate bone stiffness in distraction osteogenesis.

The newly formed regenerate bone during limb lengthening usually is assessed by observing standard plain radiographs. However, no objective data correlate the radiographic appearance with the quantitative strength of the newly formed bone. A noninvasive method was developed to assess the regenerate bone using digital radiography. The investigations were performed in a micropig animal model. The right tibia was distracted for 10 days at 2 mm per day. Digital radiography was performed after the distraction during a 10-day consolidation period. For quantitative analysis, an aluminum step wedge was placed on all images, and a region of interest was outlined in the regenerate bone. A calibration curve was calculated by measuring the corresponding gray values of the aluminum phantom. The calibration equation was used for determining the mean density in the region of interest. This method was sensitive in assessing day to day healing progress. The measurements taken the day before sacrifice were compared with torsional mechanical data using a material testing machine. The high correlation between the densimetric evaluations and the biomechanical data suggests this method is a useful tool for in vivo assessment of the regenerate bone during the consolidation period in distraction osteogenesis.

Absorptiometry, Photon↗
PubMed1996

The impact of total enteral nutrition on distraction osteogenesis in a rat model.

Limb lengthening by gradual mechanical distraction, termed distraction osteogenesis (DO), results in new bone formation. We have developed a rat tibial model for DO and have proceeded to study the effects of nutrition on this process. We have combined the intragastric diet delivery system of total enteral nutrition (TEN) with DO in the rat model. The first study was designed to address the weight loss associated with DO in dogs and patients. Rats in the chow + DO group lost 10% body weight over the 20-day distraction period but gradually gained weight back to the preoperative level by the end of the 5th week of the bone consolidation period. In contrast, in the TEN + DO group, a weight gain was recorded during the 20-day distraction phase. A second study was conducted to determine the effects of TEN on the rate and histology of regenerate bone formation. The weight changes replicated those seen in the first study. Standardized radiographs, taken on day 20, revealed increases (p < 0.003) in regenerate bone formation in the TEN group when compared with the chow group. Increased numbers of osteoclasts in the TEN group may indicate an accelerated entry into the remodeling phase of consolidation. Serum IGF-I values, taken at day 20, did not differ between the groups. These results demonstrate that the nutritional support dramatically increased the mineralized bone formed over the 20-day distraction period.

Animals↗
PubMed2002

Minimally invasive plate osteosynthesis (MIPO) combined with distraction osteogenesis in the treatment of bone defects. A new technique of bone transport: a report of two cases.

This study reports two cases of fracture of the femur with segmental bone loss that were treated by a new technique of bone transport. A minimally invasive plate osteosynthesis (MIPO) bridge from the proximal to distal femur served as a fixation system. A separate Wagner distraction apparatus was used for distraction osteogenesis. After the transport segment docked with the bone fragment, it was fixed to the plate by a percutaneous screw fixation. The Wagner lengthening device was then removed. The total time of external fixation was significantly reduced. A satisfactorily functional result and bone segment regeneration was achieved. The external fixation index was 0.31 and 0.37 month/cm, and the limb length discrepancy was 0.9 and 1.2cm. The advantages of this technique include a decrease in the duration of external fixation, protection against refracture and earlier rehabilitation.

Adolescent↗
PubMed2001

Craniofacial distraction osteogenesis: a review of the literature: Part 1: clinical studies.

A review of the literature dealing with distraction osteogenesis (DO) of the craniofacial skeleton, provided by a PUBMED search (National Library of Medicine, NCBI; revised 3 April 2000) from 1966 to December 1999 was conducted. Key words used in the search were distraction, lengthening, mandible, mandibular, maxilla, maxillary, midface, midfacial, monobloc, cranial, craniofacial and maxillofacial. This search revealed 285 articles. One hundred and nine articles were clinically orientated and were analysed in detail in this study. The type of distraction, indications, age, type of surgery, distraction rates and rhythms, latency and contention periods, amount of lengthening, follow-up period, relapse, complications and the nature of the distraction device were analysed. This review revealed that 828 patients underwent DO of the craniofacial skeleton; 579 underwent mandibular DO, 129 maxillary DO, 24 simultaneous mandibular and maxillary DO and 96 midfacial and/or cranial DO. Craniofacial DO has proven to be a major advance for the treatment of numerous congenital and acquired craniofacial deformities. Treatment protocols and success criteria for craniofacial DO are suggested on the basis of these results. There is still, however, a lack of sufficient data, especially on follow-up and relapse, so that treatment strategies have to be validated by long-term studies in the future.

Adolescent↗
PubMed2002

Treatment of condylar hypoplasia with distraction osteogenesis: a case report.

This report describes the surgical-orthodontic treatment procedures of a patient with condylar hypoplasia. Condylar hypoplasia is a major factor in any facial abnormality in a growing child. This case report describes a patient with a facial anomaly with an acquired unilateral condylar hypoplasia. His asymmetry was corrected by using functional therapy for the correction of muscle tonus and distraction osteogenesis for lengthening the mandibular ramal height. Fixed orthodontic appliances were used for conventional orthodontic therapy and final occlusal adjustment.

Bite Force↗
PubMed1998

Segmental mandibular reconstruction by distraction osteogenesis under skin flaps.

In five adult dogs, molars were extracted and skin flaps from the neck prepared for delayed transplantation. Two weeks later, a 25-mm segment of the mandible was excised with surrounding periosteum and gingiva. The mandible was stabilized with a reconstruction plate and the intraoral defect repaired with a pedicled skin flap. A proximal transport segment was created and an external distraction device was applied. After one week, distraction of the transport segment was begun at a rate of 1 mm/day. After distraction was completed, the lengthening appliance was left in place for 12 weeks until the dogs were killed. Radiologic and histologic examination revealed new bone at the distraction site. The intraoral skin flap was pushed out of the defect as distraction progressed. Bony union of the transport segment to the distal stump was not achieved due to intervening soft tissue. These results suggest that it is feasible to bridge a mandibular defect that is covered with a skin flap, with distraction osteogenesis.

Animals↗