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PubMed2004

Distraction osteogenesis of the cranial vault for the treatment of craniofacial synostosis.

From January 2000 to December 2001, six patients with craniosynostosis were treated. Involved sutures were coronal sutures in three patients, coronal and metopic sutures in one patient, multiple sutures (brachycephaly and oxycephaly) in one patient, and multiple sutures with a cloverleaf skull deformity in one patient. The age distribution of the patients was 4 months to 3 years. Four were male, and two were female. A frontal craniotomy was performed in four patients with brachycephaly. In one patient with brachycephaly, the osteotomies were made across the nasofrontal junction, across the roof of the orbit, and along the lateral orbital wall. In one patient with a cloverleaf skull deformity, a frontal bone osteotomy was first performed 1 cm above the roof of the orbit. A supraorbital frontal bar was then made across the nasofrontal junction, across the roof of the orbit, and down to the lateral orbital wall. The frontal bone flap was repositioned to the supraorbital bar using absorbable miniplates and screws. Distraction was started 3 to 7 days after the operation at a distraction rate of 1 mm/d. The real duration of the first operation was 90 to 120 minutes, and the second operation to remove the device took 40 to 50 minutes to perform. The distracted length was 15 to 25 mm. The consolidation period was 3 to 5 weeks. The follow-up period was 6 months to 1 year. Postoperative three-dimensional computed tomography demonstrated reossification at the bone flap and advancement of the fronto-orbital area. After surgery, the cranial volume increased 22.7% on average compared with before surgery. The mean ratio of the anteroposterior length to the transverse length of the cranial vault was changed from 0.96 before surgery to 1.04 after surgery. In conclusion, the advantages of distraction osteogenesis of the cranial vault are that it offers a less invasive technique, a shorter operation time, easy care, and postoperative safety as a result of minimal dissection of the dura. Disadvantages are the limited possibility of initial reshaping and the necessity of one more operation for device removal.

Cephalometry↗

PubMed2002

Cranio-facial distraction osteogenesis: a review of the literature. Part II: Experimental studies.

In this study the literature dealing with experimental cranio-facial distraction osteogenesis (DO) was reviewed. A PUBMED search (National Library of Medicine [NCBI] revised 1 April 2001) from 1966 through December 2000 was conducted. Key words used in the search were: distraction, lengthening, mandible, mandibular, maxilla, maxillary, midface, midfacial, monobloc, cranial, cranio-facial, maxillofacial. This search revealed a total of 120 experiment-orientated articles that were all analyzed in detail in this study. The purpose of the experimental study, animal model, animal growth status, type of distraction, type of surgery, distraction rate and rhythm, latency and contention period, amount of lengthening, relapse, complications and nature of the distraction device were analyzed. This review revealed that a total of 1207 animals were used in seven different animal models for research on cranio-facial DO: 54 using dogs (45.0%), 25 using rabbits (20.8%), 18 using sheep (15.0%), 11 using minipig (9.2%), seven using monkeys (5.8%), four using rats (3.3%) and one using a cat model (0.8%). Based on the results of this study, an attempt was made to provide biological DO parameters and guidelines for future research on experimental cranio-facial DO related to the appropriate animal model.

Animals↗

PubMed2007

Unexpected absence of effect of rhBMP-7 on distraction osteogenesis.

We asked whether locally applied rhBMP-7 with a Type I collagen carrier could enhance the consolidation phase in distraction osteogenesis. We performed unilateral transverse osteotomy of the tibia in 28 immature male rabbits. In half the animals (14 rabbits), 70 microg rhBMP-7 (28.5 mg rhBMP-7/CC, OP-1) was applied locally on the day of the osteotomy; the control group (14 rabbits) had no local application. After 7 days, 3 weeks of distraction was begun at a rate of 0.5 mm every 12 hours. Starting with Week 2 of distraction, we assessed radiographic, ultrasonographic, and densitometric parameters once per week. Animals were sacrificed after 3 weeks of distraction, and after 1, 2, and 3 weeks of additional consolidation. Radiographic evaluation revealed a tendency for increased bony union and bone differentiation in the control group compared with the rhBMP-7/CC group. The bone mineral content was higher in the control group at each time. Ultrasonographic evaluation revealed the development of a cyst in the regenerate in 92% of the animals in the rhBMP-7/CC group versus 0% in the control group. Ultrasonography and histomorphometry showed delayed regenerate development in the rhBMP-7/CC group. We suggest the poor results related to the relatively large bulk of the solid carrier of the OP-1 that might have acted as a mechanical obstacle to osteogenesis.

Administration, Topical↗

PubMed1999

A quantitative analysis of the effect of insulin-like growth factor-1 infusion during mandibular distraction osteogenesis in rabbits.

AIM: To quantify, by histomorphometry, the effects of local insulin-like growth factor-1 (IGF-1) during mandibular distraction at various rates. METHODOLOGY: Mature rabbits underwent bilateral mandibular corticotomy and distraction lengthening. Recombinant IGF-1 was administered to two groups of rabbits via osmotic infusion pumps. Distraction regimes were as follows: Group A, 1 mm/day for 15 days; Group B, as for A plus IGF-1; Group C, 3 mm/day for 5 days; Group D, as for C plus IGF-1; and Group E, sham-operated controls. After a 28-day consolidation period, rabbits were sacrificed and bone deposition quantified using DEXA scanning, three-point bending, histological examination and sampled for histomorphometric analysis. RESULTS: DEXA scanning and three-point bending failed to detect any effect of distraction rate or of IGF-1 infusion. Histological and histomorphometric analysis suggested 1 mm/day to be the ideal distraction rate, as this was associated with greater osteoblastic activity and consistent bony union. However, IGF-1 infusion significantly enhanced osteoblastic activity at both distraction rates and resulted in bony union when distraction was performed at 3 mm/day. CONCLUSIONS: Distraction osteogenesis at a rate of 1 mm/day provides greater osteogenic stimulus than 3 mm/day. Exogenous IGF-1 has a positive influence on osteoblastic activity during distraction. Its effect is probably minimised by high levels of endogenous IGF-1.

Animals↗

PubMed1997

Skeletal and dental movements after anterior maxillary advancement using implant-supported distraction osteogenesis in dogs.

PURPOSE: This study evaluated skeletal and dental relapse in the dog after anterior maxillary advancement using an implant-anchored distraction osteogenesis device. MATERIALS AND METHODS: After the placement of implants into the palate, four dogs had a skeletally anchored distraction device fabricated and an anterior maxillary osteotomy performed. The distraction device was activated 0.5 mm two times each day to advance the anterior segment 10 mm in 10 days. The dental and skeletal changes were measured and compared for 26 weeks after distraction was completed. RESULTS: Tooth and radiographic measurements indicated that on the 10th day of distraction the average tooth advancement was 6.83 mm +/- 1.75 mm SD, and the average skeletal advancement, based on radiographs, was 8.67 mm +/- 1.25 mm SD. After 10 weeks, the average tooth advancement was 4.0 +/- 1.73 mm, and the average skeletal advancement was 8.67 +/- 3.59 mm. After 26 weeks, the average tooth advancement was 3.65 +/- 1.69 mm, and the average skeletal advancement was 8.0 +/- 1.98 mm. Bone healing occurred in all animals. The skeletal advancement 26 weeks after distraction was 85% of the initial advancement. The teeth adjacent to the distraction site initially moved 68% of the advancement, but the distance between the teeth subsequently decreased, with a resultant 36% advancement compared with the initial advancement. CONCLUSION: This study showed that skeletal fixation will result in bone movement greater than dental movement, indicating the need for skeletal anchorage to advance the maxilla.

Animals↗

PubMed1999

The role of chondrocytes in intramembranous and endochondral ossification during distraction osteogenesis in the rabbit.

We have used a rabbit leg-lengthening model for detailed studies of the histology of distraction osteogenesis. Some unusual features of the endochondral ossification that occurs during the rapid transition of cartilage to bone in the regenerate were observed. Histological staining techniques together with immunohistochemistry and nonradioactive in situ mRNA hybridization for cartilage and bone-related molecules have been used to document the presence of an overlapping cartilage-bone phenotype in cells of the cartilage-bone transitional region. In those particular areas, some chondrocytes appeared to be directly transformed into newly formed bone trabeculae which are surrounded by bone matrix. Acid phosphatases were found within the cartilage matrix in some of the cartilage/bone transitional regions and type I collagen mRNA and type II collagen protein were found together in some of the marginal hypertrophic chondrocytes. This study indicates an unusual role of chondrocytes in the process of ossification at a distraction rate of 1.3 mm/day in the rabbit. Further direct evidence is required to prove the hypothesis that the hypertrophic chondrocytes may transdifferentiate into bone cells in this model.

Acid Phosphatase↗

PubMed2004

Distraction osteogenesis of the nasal and antral osseous floor to enhance alveolar height.

PURPOSE: The purpose of the study was to obtain information on the possibility of using distraction osteogenesis (DO) to increase the height of posterior atrophic maxillary alveolar ridges by distracting very small alveolar crest bone segments and, secondly, to determine if it is possible to distract the bony antral floor itself, producing new bone between the sinus membrane and the alveolar crest. MATERIALS AND METHODS: Three adult Papio anubis baboons were rendered edentulous in the posterior maxilla. Bilateral osteotomies were performed to produce a thin margin of crestal alveolar bone and in one area, a complete exposure of the antral floor. Distractors were placed against the antral and nasal floors and the thin 1- x 1.5-mm thick alveolar bone crest was distracted 10 mm over a period of 10 days. Animals were labeled with tetracycline at 3 and 4 months and were sacrificed at 5 months. RESULTS: A complete osseous regeneration of the nasal floor and alveolar ridge greater than 10 mm in height was produced in all cases. Histomorphometric analysis of the DO-induced osseous areas revealed cancellous bone with increasing thickness during the third and fourth month and formation of new bone cortices increasing in thickness during the same time. Significant new bone also formed in the antral floor areas that had been purposely interdicted by the osteotomies. CONCLUSION: The results of this study indicate that very small segments of bone of the posterior maxilla can be distracted to produce significant increases in the alveolar bone height and that a new osseous nasal-antral floor enhancement can be produced by this technique.

Alveolar Ridge Augmentation↗

PubMed2005

Mandibular advancement by distraction osteogenesis for tracheostomy-dependent children with severe micrognathia.

PURPOSE: The purpose of this study was to evaluate mandibular lengthening by distraction osteogenesis (DO) to achieve decannulation of micrognathic children with "permanent" tracheostomies. PATIENTS AND METHODS: Using a retrospective chart review, patients were included who had 1 ) airway compromise/tracheostomy, 2 ) micrognathia, 3 ) polysomnography-documented obstructive apnea, and 4 ) mandibular advancement using DO. Excluded were 1 ) adults, 2 ) neonates without tracheostomy, and 3 ) patients with central apnea. Patient age, past medical history, age at tracheostomy, and distraction protocol were documented. Oxygen saturation, posterior airway space (in millimeters), and sella-nasion-B point (SNB) angle were recorded. The distraction protocol consisted of a latency of 48 hours and a rate of 1 mm/day. RESULTS: There were 5 children, aged 2 to 14 years, who received a tracheostomy between ages 2 and 36 months for airway obstruction. All patients underwent bilateral mandibular distraction using semiburied, unidirectional devices. The average latency was 58 hours, the rate was 1 mm/day, the duration of fixation was 40 to 60 days, and the magnitude of advancement was 23 mm. Healing was evaluated by clinical, radiologic, and ultrasound examinations. No complications were experienced. Mean follow-up was 3.2 years. Postdistraction sleep studies demonstrated no obstructive apneic events and a mean oxygen saturation of 98% (preoperative, 76%, P < .005). Cephalometric values improved: posterior airway space 4 to 14 mm; SNB 66 degrees to 72 degrees ( P < .005 for both variables). Four of the 5 patients have been successfully decannulated to date. CONCLUSIONS: The results of this preliminary study indicate that mandibular advancement by DO is a potentially viable treatment option for tracheostomy-dependent children with upper airway obstruction secondary to micrognathia.

Adolescent↗

PubMed2004

Biomechanical evaluation of mandibular midline distraction osteogenesis by using the finite element method.

The aim of this study was to evaluate the biomechanical effects of mandibular midline distraction osteogenesis on the mandibular complex by using a 3-dimensional finite element model, whose construction was based on computer tomography scans of the mandible of a 22-year-old man. The computer tomography pictures were transferred and converted to the finite element model by means of a procedure developed for this study. The final mesh consisted of 1314 solid elements with 3076 nodes. The distraction was performed on the middle intersection point of the vertical and horizontal planes on the mandibular symphysis. The mechanical response in terms of displacement and von Mises stresses was determined by widening the mandible up to 5 mm on both sides. The results indicate that the mandible was separated almost in a parallel manner (4.45-5.0 mm separation from the mandibular incisors to the lower border of the mandibular symphysis and 4.09-4.92 mm from the mandibular canines to the symphyseal border at the canine region), superoanteriorly. Anteroposterior evaluation demonstrated that the greatest widening was achieved at the symphyseal region, and the widening effect gradually decreased from anterior to posterior. Viewed occlusally, the width of the mandibular bone at the symphyseal region increased remarkably, whereas the ramal and gonial regions of the mandible and the condyle had shown minimal displacement. Mandibular bone was displaced forward and slightly downward. The highest stress levels were observed bilaterally below the condylar areas. High stress levels were also observed in the ramal region of the mandible.

Adult↗

PubMed2002

Response of patients and families to lengthening of the facial bones by extraoral distraction osteogenesis: a review of 14 patients.

Fourteen patients or their immediate family were interviewed about their experiences of having either unilateral or bilateral external distraction osteogenesis of the mandible. The patients showed a high level of co-operation with treatment. Six of the 14 patients required repeat distractions, and had been informed and accepted that this was a possibility before the initial distraction. However, patients or their parents expressed some reservations about the extraoral distractors, which prevented them from practising their favourite sport and made them vulnerable to bullying by their friends and colleagues. Patients had moderate pain when the appliances were removed. They all expressed their satisfaction with the results and would recommend this treatment to others. Problems, including speech, eating, pain, and sleeping difficulties, were encountered by patients at all stages of treatment. Of considerable concern was the disruption of education when the child was treated during the school term.

Absenteeism↗

PubMed1998

Histochemical and molecular analyses of distraction osteogenesis in a mouse model.

A tibial lengthening scheme in the mouse was used to study the molecular and cellular events regulating tissue regeneration during distraction osteogenesis. Here, we report on the surgical technique and frame design and describe the histochemical and molecular aspects of distraction during different phases of treatment. A total of 26 mice were used in this study. The treatment protocol was divided into a latency period of 7 days, a phase of active distraction that lasted 10 days with a distraction rate of 0.42 mm/day, and a maturation phase of 9 days. During latency, the distraction site resembled a stabilized fracture callus on both a histochemical and a molecular level. During active distraction, the gap was characterized by a central fibrous interzone bordered by primary matrix fronts, regenerate bone aligned with the distraction force, parallel columns of vascular sinusoids, and a medullary cavity. Alkaline phosphatase activity was detected in the endosteal and periosteal surfaces of the bone ends. Tartrate resistant acid phosphatase staining revealed that osteoclasts remodeled the bone regenerate as it formed. Collagen type I was expressed in the periosteum and the primary matrix front during distraction, whereas collagen type-II transcripts were localized to discrete regions on the periosteal surfaces, immediately adjacent to the osteotomy ends. Collagen type-II transcripts were not detected in the fibrous interzone. During the maturation phase, cells within the fibrous interzone expressed collagen type I and exhibited abundant alkaline phosphatase activity, suggesting that they had begun to terminally differentiate. Collectively, these data demonstrate the utility of a mouse model to study the molecular and cellular bases for the regeneration and remodeling of tissue.

Acid Phosphatase↗

PubMed2001

Changes in speech following unilateral mandibular distraction osteogenesis in patients with hemifacial microsomia.

OBJECTIVE: The purpose of this study was to describe changes in articulation, resonance, and velopharyngeal function following mandibular distraction osteogenesis. DESIGN: This is a descriptive, post hoc study comparing the performance of patients on measures of articulation, resonance, and velopharyngeal function before and after mandibular distraction. SETTING: The data were collected at a tertiary health care center located in Chicago. PATIENTS: The clinical data from preoperative and postoperative evaluations of seven mandibular distraction patients were used. OUTCOME MEASURES: The outcome measures were number of articulation errors, severity of hypernasality and audible nasal emission, and velopharyngeal orifice size as estimated using the pressure-flow technique. RESULTS: Immediately after distraction, 28% (2/7) experienced a temporary deterioration in articulation and 42% (3/7) experienced a deterioration in nasal resonance. But by the long-term follow-up evaluation, all had returned to their preoperative levels. Pressure-flow test results generally support the perceptual findings. CONCLUSIONS: Patients being considered for mandibular distraction surgery should receive preoperative and postoperative speech evaluations and be counseled about risks for changes in their speech following surgery.

Adolescent↗

PubMed2004

[Mid-premaxillary sutural distraction osteogenesis for repair of alveolus cleft: an experimental study in dogs].

OBJECTIVE: To explore a new technique for repair of alveolar cleft by sutural distraction osteogenesis. METHODS: Nine 8-weeks mongrel dogs were used in this study, three being in the control group, six in the experimental group. Alveolar cleft model was created surgically in all animals. Two weeks later, a U-shaped distractor made of Ni-Ti memory alloy wire was insterted into the premaxilla to distract the mid-premaxillary suture. When the premaxilla of the cleft side approached the ipsilateral maxilla, periosteoplasty of the alveolar cleft was performed. The distractor was removed at two weeks after periosteoplasty. The results were evaluated clinically, radiographically, morphologically and histologically. RESULTS: The cleft model in dogs was stable and similar to the human alveolar cleft. In experimental dogs, the premaxilla was moved gradually toward the maxilla so that the cleft was closed. The distracted mid-premaxillary suture showed a gradually widened traingle, with its tip being posterior. The density of the distracted traingle suture was increased gradually. Bony repair was achieved completely at the cleft three months post-periosteoplasy. The morphology of the mid-premaxillary suture was restored. CONCLUSION: The alveolar cleft could be repaired by the technique of mid-premaxilla suture distraction.

Alveoloplasty↗

PubMedDate not supplied

Treatment of rigid hypertrophic posttraumatic pseudarthrosis of the tibia in children using distraction osteogenesis.

Posttraumatic tibial pseudarthrosis is a relatively uncommon complication of tibia fractures in children. Although reported as a successful method of treating tibial nonunions in adults, distraction osteogenesis through a nonunion site via ring external fixation has not been described in children. The authors report three consecutive cases of distraction through an angulated, shortened, hypertrophic, posttraumatic nonunion to achieve successful union and concurrent correction of deformity. Distraction was carried out using a ring fixator with computer-guided correction. Union was achieved in each of the three patients with complete correction of deformity and length. Lengthening of 8 to 31 mm was achieved. The length of time in the external fixator ranged from 7 to 27 weeks. Pin tract infections developed in all patients; they were treated successfully using oral antibiotics. No deep infections or other significant complications developed. Each patient was followed up for at least 1 year.

Accidents, Traffic↗

PubMed2006

A new approach to repairing cleft palate and acquired palatal defects with distraction osteogenesis.

Cleft palate (CP) is one of the most common human congenital deformities, and acquired palate defects after trauma or tumour resection are also common. In this study, distraction osteogenesis (DO) for CP and other palatal bone defects was evaluated. Twenty cats were assigned randomly to 3 groups of (1) 15, (2) 3 and (3) 2 cats. In groups 1 and 2, a rectangular ostectomy, in the posterior of the palatal bone shelf, was performed in the sagittal axis to establish the CP defect model. At the same time, a pure titanium intraoral distractor was fixed to molar teeth with brackets and to the palatal bone shelf across the defect with titanium miniscrews bilaterally. Four weeks later, a secondary transport disc (TD) osteotomy was performed, and gradual DO treatment started at 0.4mm twice a day, after 6 days of latency. DO was performed until the TD reached the opposite margin over the gap in 5-6 days. Three cats each of group 1 were killed at 2, 4, 6, 8 and 12 weeks after completion of DO. In group 2, the bone and soft-tissue defects were untreated until death 6 weeks later. Group 3 cats (control) were killed after 6 weeks. The TD successfully recombined with the opposite palatal bone stump, and proportional expansion of the overlay mucoperiosteal flap was achieved. Intramembranous bone formation was revealed: parallel collagen bundles gradually deposited on new bone trabeculae while the proliferative osteoblasts produced bone matrix. The bone defect was finally reconstructed by de novo osteogenesis. The control group was observed to have no spontaneous repairing. These results suggest that the CP defect was reconstructed by osteogenesis in situ, and the soft tissues expanded simultaneously to achieve functional correction. The intraoral distractor provided both effective distraction and stability.

Animals↗

PubMedDate not supplied

Reliability of radiographic assessment of distraction osteogenesis site.

The presence of three of four continuous cortices on anteroposterior and lateral radiographs has been stated to be an indication of bony healing of distraction osteogenesis. In this study the authors assessed the level of agreement of radiographic assessment of bony union. Forty-two lower extremity radiographs of consolidating distraction gaps were reviewed by nine examiners on two occasions for number of cortices and whether fixator removal was indicated. For number of cortices, the kappa coefficients for interobserver and intraobserver variability were 0.127 and 0.290. For fixator removal, the interobserver and intraobserver coefficients were 0.352 and 0.461. Variation in assessment of number of cortices was slightly better than chance, indicating an inadequate measure of healing. The clinicians used radiographic criteria other than three of four cortices for fixator removal. The decision to remove an external fixation device based on radiographic assessment alone resulted in intraobserver and interobserver variability moderately above chance.

Device Removal↗

PubMed1998

Distraction osteogenesis and its application to the midface and bony orbit in craniosynostosis syndromes.

The purpose of this study was to demonstrate the potential advantages of applying distraction osteogenesis techniques to the correction of orbital and midfacial hypoplasia in craniosynostosis syndromes. Fifteen children with various craniosynostosis syndromes underwent Le Fort III advancement assisted by gradual distraction utilizing a pair of internal distraction devices custom-fabricated for each child. The surgical procedure consisted of a Le Fort III osteotomy, implantation of internal devices with initiation of distraction intraoperatively, and an accelerated rate of midfacial advancement over the next 3 to 5 days. Activation of the distraction hardware was accomplished by a percutaneous pin, which was removed at the end of the distraction protocol, allowing the internal devices to fixate the fragment for a minimum of 6 months during the period of consolidation. With follow-up ranging between 3 to 38 months, the average orbital and midfacial advancement was 19.7 mm (range, 12.0-30.0 mm). Proptosis was lessened and facial proportions significantly improved in all patients. Serious complications were not encountered. The modified distraction protocol utilized in this group of patients was aimed at addressing the unique requirements of pediatric craniofacial surgery, and resulted in almost twice the amount of correction previously reported for traditional rigid fixation techniques.

Adolescent↗

PubMed2000

Growth factor modulation of distraction osteogenesis in a segmental defect model.

A model was established in 39 dogs to investigate the growth factor modulation of regenerate bone in distraction osteogenesis. A segment of the diaphysis of the radius was resected unilaterally. An osteotomy was made proximal to the segmental defect to create a transport segment. A monolateral external fixator was applied. After a latency period, the segment was transported across the defect. One week after the transport assembly contacted the distal pin clamp, an ipsilateral osteotomy of the proximal ulna was performed. In 20 dogs, transforming growth factor-beta was injected into the regenerate bone halfway through the transport period. Four dogs were sacrificed before docking, when the regenerate bone was still immature. In specimens harvested halfway through the transport period, evidence was found of intramembranous ossification during distraction. In specimens harvested after the transport assembly contacted the distal pin clamp, evidence was found that the mature regenerate formed by endochondral ossification. Therefore, a combined mechanism of ossification is proposed for this segmental defect model that includes mechanical stimulus for bone differentiation. The one-time administration of transforming growth factor-beta retarded the formation of a stable, united regenerate. It is concluded that transforming growth factor-beta caused an effect opposite to that which was desired.

Animals↗