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PubMed2002

Bone-lengthening for symbrachydactyly of the hand with the technique of callus distraction.

BACKGROUND: Bone-lengthening in the hand and foot is a relatively new application for distraction osteogenesis. We present the operative treatment and postoperative outcome for four patients with M ller type-D symbrachydactyly of the hand who underwent metacarpal lengthening with use of a distraction device to establish pinch function. METHODS: Four patients who underwent distraction osteogenesis for the treatment of congenital symbrachydactyly of the hand were evaluated over a thirteen-year period. The nondominant right hand was treated in two patients, and the nondominant left hand was treated in the other two. The patients included three boys and one girl; all patients had the operation between the ages of five and eleven years. Distraction osteogenesis was performed on the fifth metacarpal in one patient and on the fourth and fifth metacarpals in the remaining three, in whom both bones were lengthened simultaneously with use of a single device. Postoperative bone elongation was analyzed with radiographs made at the time of removal of the distractor. The sensory function of the treated fingers and any growth disturbance of the distracted bones were evaluated. RESULTS: The mean duration of distraction was 37.3 days (range, thirty-two to forty-nine days), and the distractor was removed at a mean of eighty-four days after surgery. The bones were lengthened by a mean of 22.3 mm (81.6% of their original length) at a rate of 0.6 mm/day. Pinch function was improved in all patients. CONCLUSIONS: On the basis of our limited experience, we found that distraction osteogenesis of the metacarpals was an effective technique for the establishment of pinch function. We also found that an intramedullary Kirschner wire could maintain the alignment of the osteotomized bone. Although distraction requires a longer treatment period, it is apparently more effective than bone-grafting in terms of achieving adequate bone length. Simultaneous lengthening of two metacarpals also was found to be an effective technique.

Child↗

PubMed2006

Cranial vault distraction: its illusionary effect and limitation.

BACKGROUND: Distraction osteogenesis has some advantages, such as less hazardous complications, less scarring, and fewer bone defects. However, it has not been fully accepted yet because of a unidirectional expansion along the distraction device. Because cranial expansion is limited by scalp tension and soft-tissue scarring, undercorrection of the cranium and relapse of the vault deformities have occasionally been seen on long-term follow-up. These patients also had so much bone defect that the donor bone was inadequate for immediate revisions, and dissection under the scalp was complicated. METHODS: The authors used distraction osteogenesis to treat 12 cases of craniosynostosis. Five patients were syndromic (two cases of Pfeiffer's syndrome, two cases of Crouzon's disease, and one case of Apert's syndrome), and seven were nonsyndromic (four cases of brachycephaly, two cases of scaphocephaly, and one case of plagiocephaly). RESULTS: After only unidirectional expansion without vertical reduction, the shape of the cranium was satisfactorily improved, which might have been an illusion caused by the relative reduction attributed to the elongation by the distraction osteogenesis and, in brachycephaly, alteration of the patient's head position resulting from inclination of the facial plane by forehead advancement. However, in scaphocephaly, the unique deformity in the occipital and frontal regions remained after simple distraction. Distraction osteogenesis should be applied for a narrow cranium because the bone defect and scalp closure could pose problems. Radical reshaping should be used in cases of sufficient donor bone and scalp closure. Although additional surgery is unavoidable for device removal, minor revisions can be performed for revision of the irregularity at that time. CONCLUSION: Except for prolonged treatment, based on minimally invasive operations, distraction cranioplasty might be applied extensively in cases of craniosynostosis.

Acrocephalosyndactylia↗

PubMed2003

[Reconstruction of segmental mandibular defect of canine using titanium-nickel distractor].

OBJECTIVE: To establish a continuous and automatic distraction osteogenesis technique in reconstruction of segmental mandibular defect by using embedded titanium-nickel alloy distractor with characteristics of shape-memory and super-elasticity. METHODS: Adult hybrid canines were used as the animal model. Segmental defects of 1-3 cm in the body of mandible were created by surgical osteotomy. Bi-focal distraction osteogenesis was applied using embedded titanium-nickel distractor designed by the authors. The canines were sacrificed 3 months after the operation and the mandibles were harvested to examine the results of bone regeneration. RESULTS: The histocompatibility of titanium-nickel distractors was good. Distraction osteogenesis was completed automatically and the defects were elementarily restored. Radiological and histological examination showed well bone regeneration in distraction area. CONCLUSIONS: Distraction osteogenesis using embedded self-loading titanium-nickel distractor could be a hopeful and useful technique. It might help to solve the problems of functional mandibular reconstruction in the near future.

Animals↗

PubMed2004

Mandibular distraction to relieve airway obstruction in children with cerebral palsy.

OBJECTIVE: To determine the effectiveness of distraction osteogenesis of the mandible for relief of airway obstruction in neurologically impaired children. DESIGN: Prospective pilot study. SETTING: Tertiary care children's hospital. PATIENTS: Five children with upper airway obstruction secondary to hypotonia were identified by airway endoscopy, pulse oximetry, and polysomnography. Four children were tracheotomy-dependent because of upper airway obstruction, and 1 was being considered for tracheotomy because of progressive airway obstruction. INTERVENTIONS: All patients underwent distraction osteogenesis of the mandible for relief of their airway obstruction. MAIN OUTCOME MEASURES: Treatment success was determined by endoscopy, continuous pulse oximetry, and polysomnography. RESULTS: Four of the 5 children underwent distraction osteogenesis of the mandible with successful resolution of airway obstruction or tracheotomy decannulation. One child did not show adequate improvement of upper airway obstruction and remained tracheotomy-dependent. Follow-up was 2 to 40 months. CONCLUSIONS: Children with cerebral palsy and hypotonia of the upper airway may achieve relief of their chronic airway obstruction following distraction osteogenesis of the mandible. Appropriate selection criteria must be adhered to, including demonstration of tongue base obstruction on flexible laryngoscopy.

Airway Obstruction↗

PubMed2000

[Recombinant growth hormone accelerates regenerate consolidation in distraction osteosynthesis].

Distraction osteogenesis is a good model for evaluation of fracture healing with intramembranous bone formation. The purpose of the present study was to investigate whether homologous GH has a stimulating effect on bone healing in distraction osteogenesis. The left tibiae of 30 micropigs were osteomized and distracted with an external fixator 2 mm daily over a period of 10 days. Animals were killed after an additional healing time of 10 days. The treatment group received 100 micrograms r-pGH per kg bodyweight per day. A newly developed device allowed non-destructive torsional biomechanical evaluation of the regenerate strength as in vivo measurements. After killing, destructive torsional strength testing of the sites of distraction was performed. To determine the endocrine response to the administration of r-pGH, serum levels of IGF-I were determined. The non-destructive 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 the preoperative base level in the treatment group and remained unchanged in the control group. Our data indicate that systemic administration of recombinant homologous growth hormone significantly accelerates ossification of bone regenerate in distraction osteogenesis.

Animals↗

PubMed2002

[Changes in the inferior alveolar vessels and angiogenesis following mandibular lengthening with different rates of distraction].

OBJECTIVE: The purpose of this study was to study the changes in the inferior alveolar vessels and angiogenesis following mandibular lengthening with different rates of distraction. METHODS: Bilateral mandibular corticotomies were performed in 6 goats. The mandibles in 6 goats were lengthened 10.0 mm using a custom-made distractor with different rates of distraction (1.0 mm/d[n = 3] and 2.0 mm/d [n = 3]); the other 2 nondistracted mandibles served as control. The goats with distracted mandibles were killed at 2 weeks after completion of distraction. The inferior alveolar vessels with distracted calluses were harvested and processed for histologic and morphometric evaluation. RESULTS: No pathological changes in the inferior alveolar vessels were found following mandibular osteodistraction. However, the number of microvessels within distraction gap in the animals distracted at a rate of 1.0 mm/day was greater than that in the goats distracted using a rate of 2.0 mm/day, and more mature newly formed bone trabeculae was observed. CONCLUSION: There were no significant changes in the inferior alveolar vessels after mandibular lengthening with distraction osteogenesis, but rapid distraction may have adverse effects on the aniogenesis in the distraction gap.

Alveolar Process↗

PubMed2001

Alveolar distraction: a possible new alternative to bone grafting.

Distraction osteogenesis is a new concept to periodontics that may replace the more traditional bone grafting techniques of onlay grafts and titanium membrane procedures. Distraction osteogenesis is not fraught with the complications of graft and membrane exposure or inadequate tissue coverage, which makes the distraction procedure an ideal technique to grow unlimited amounts of vertical bone height. This article describes a technique to grow new bone and soft tissue in a maxillary alveolar defect using a new technique called alveolar distraction osteogenesis. A case report is presented of the distraction procedure, reentry 6 months later, implant placement, and restoration.

Adult↗

PubMed2002

Computer-aided procedures in implantology, distraction and cranio-maxillofacial surgery.

Smaller implants and less invasive techniques for osteotomies using an endoscope assisted approach may facilitate the surgical procedures in cranio-maxillofacial distraction osteogenesis. Although sophisticated distraction devices are routinely used, there are still certain problems which need to be addressed. The preoperative planning, even of complex cases can be facilitated by using modern imaging techniques such as computer assisted surgery (CAS). The placement of the devices and the outline of complex osteotomies can be controlled intra-operatively. CAS allows for postoperative monitoring and for the long term follow up. The vector of distraction can be monitored and, depending on the device, a change of the vector of distraction may be possible during the activation period.

Cephalometry↗

PubMed2006

Guided tissue regeneration enhances bone formation in a rat model of failed osteogenesis.

BACKGROUND: Guided tissue regeneration is a technique that uses barrier materials to enhance tissue regeneration. Although previously demonstrated to be an effective way of enhancing craniofacial osteogenesis in several animal models, the ability of guided tissue regeneration to augment bone formation in the context of distraction osteogenesis is unknown. In the current study, the authors applied the principle of guided tissue regeneration to their rat mandibular distraction osteogenesis model in an attempt to enhance bone regeneration. METHODS: Twelve (n = 6 per group) adult Sprague-Dawley rats underwent routine gradual distraction (5 days' latency, 4-mm distraction over 8 days, 4 to 6 weeks of consolidation) and acute distraction (immediate lengthening to 4 mm, 6 to 8 weeks of consolidation). An additional 10 animals underwent acute distraction followed by application of bioabsorbable Gore Resolut XT membranes (acute distraction plus guided tissue regeneration). Membranes were completely wrapped around the distraction gap. Animals were killed 6 and 8 weeks postoperatively and mandibles analyzed radiographically and histologically. RESULTS: Quantitative histomorphometric analyses were performed to compare relative bone formation between all three groups. Gradual distraction mandibles achieved bony union by 6 weeks with 86 percent bone formation, which increased to 98 percent by 8 weeks. Acute distraction mandibles healed with a fibrous nonunion and only 37 percent bone formation by 8 weeks. In contrast, acute distraction plus guided tissue regeneration-treated mandibles formed significantly more bone than acute distraction mandibles by 6 weeks (57 percent) and achieved bony bridging by 8 weeks, with 88 percent new bone formation. CONCLUSION: The authors' data demonstrate that guided tissue regeneration can significantly enhance bone formation in a fibrous nonunion model of mandibular distraction osteogenesis.

Animals↗

PubMed2004

Inferior subluxation of the fibular head following tibial lengthening with a unilateral external fixator.

BACKGROUND: Inferior subluxation of the proximal part of the fibula has been reported to occur with distraction osteogenesis of the tibia; however, the clinical sequelae of this subluxation are unknown. The purpose of this study was to evaluate inferior subluxation of the proximal part of the fibula and its possible clinical implications in patients who had undergone tibial lengthening by distraction osteogenesis with use of a unilateral external fixator. METHODS: Thirty tibiae in seventeen patients with a variety of conditions underwent tibial lengthening by distraction osteogenesis with use of a unilateral external fixator and were followed clinically and radiographically for a mean of two years and ten months (range, two to four years). Ten patients were female and seven were male. Their mean age at the time of the surgery was seventeen years (range, eight to twenty-five years). The mean tibial lengthening was 8.1 cm (range, 3.5 to 13 cm). RESULTS: An inferior shift of the fibular head in relation to the tibia was evident in all cases. The shift, which ranged from 0.4 to 3.3 cm, was proportionally related to the amount of tibial lengthening. This type of subluxation is probably attributable to the tension that is exerted by the intact interosseous membrane during the distraction as well as to the tension of the regenerated bone of the fibula and the fact that the fibula itself is not fixed or directly lengthened by the external fixator. CONCLUSIONS: It appears that inferior subluxation of the fibula is a common phenomenon in patients undergoing tibial lengthening by distraction osteogenesis with use of a unilateral external fixator. However, no clinical symptoms or findings related to the inferior subluxation of the fibula were found in our series.

Adolescent↗

PubMed1999

Midface distraction.

Since the initial application of distraction osteogenesis to the human mandible by McCarthy, distraction osteogenesis has been used for gradual lengthening of the midface in children with syndromic craniosynostosis, cleft lip and palate, hemifacial microsomia, and midface hypoplasia from other causes. Both external and internal devices are available that permit midface distraction. The background of midface distraction and the development of a Modular Internal Distraction (MID) system that permits widespread use of easily customized, buried distraction devices throughout the craniofacial region are presented. The relative and potential clinical indications for distraction, treatment planning, patient preparation, and possible surgical orthodontic interactions during distraction, as well as a variety of case examples showing the MID system, are discussed.

Acrocephalosyndactylia↗

PubMed2006

[Analysis of the complications following mandibular distraction using internal distractors].

OBJECTIVE: To investigate the causes and the prophylactic for the complications following mandibular distraction osteogenesis using internal distractors. METHODS: From 1997 to 2004, a total of 46 patients (61 sides) suffering from malformations or defects of mandible who underwent mandibular distraction osteogenesis were analyzed. The diseases included hemifacial microsomia in 27 cases, congenital or acquired mandibular hypoplasia and micrognathia bilateral in 8 cases and unilateral in 4 cases, electronical injury or postoperative mandibular defects in 3 cases, Treacher Collins syndrome in 2 cases, obstructive sleep apnea syndrome in 2 cases. RESULTS: Of them, 9 patients had postoperative complications, which included 3 patients had complications associated with distractors, local infection occurred in 2 cases, apertognathia of anterior teeth in 2 case, 2 patients had sinus of the skin of the lower lip. 9 patients had been aggressivly managed and obtained satisfactory results. CONCLUSIONS: The pivotal points to reduce complications are to understand the mechanism of mandibular distraction osteogenesis completely, and to be familiar with the anatomy of mandible and adjacent tissues. It is necessary to treat with it preoperatively and postoperatively.

Adolescent↗

PubMed2001

Internal Le Fort III distraction with biodegradable devices.

Shortly after the initial application of distraction osteogenesis to the human mandible by McCarthy, distraction osteogenesis was used for gradual lengthening of the midface in children with syndromic craniosynostosis, cleft lip and palate, hemifacial microsomia, and midface hypoplasia from other causes. Both external and internal devices are available for midface distraction. In spite of the many advantages of internal metallic distraction devices, they can be more difficult to remove. By substituting the metallic fixation plates of the Stryker-Leibinger Modular Internal Distraction system, with resorbable MacroPore fixation mesh, only the distractor screw and cable drive need to be removed. Moreover, by using a resorbable stabilizer, the screw and cable components are not needed for the consolidation phase, and can be removed at the completion of active distraction. In this case report of a 4-year-old girl with Crouzon's syndrome, contouring of the resorbable distraction devices was performed using a sterilizable model, 20 mm of distraction was achieved, and 4 days later the distractor screw was replaced with a resorbable stabilizer, resulting in an excellent correction of her midface hypoplasia.

Absorbable Implants↗

PubMed2000

Loaded hydroxylapatite-coated implants and uncoated titanium-threaded implants in distracted dog alveolar ridges.

AIMS: The aim of this study was to determine the response of alveolar bone after it was augmented vertically with distraction osteogenesis, implanted with hydroxylapatite (HA)-coated implants and noncoated titanium-threaded implants, and subsequently loaded for 1 year. METHODS: Eight dogs each had 4 implants placed horizontally into an edentulous mandibular quadrant. After integration, a distraction osteogenesis device was fabricated in the laboratory. An osteotomy was made to allow the crest of the alveolar ridge to be distracted vertically. After 10 mm of vertical distraction, the distraction devices were stabilized with light cured resin. After bone fill of the distraction gap was radiographically confirmed in all dogs at 10 weeks, 2 implants were placed into the ridges. Four dogs had threaded titanium implants placed, and 4 dogs had threaded HA-coated implants placed, with 1 implant in the distracted bone and 1 implant in adjacent nondistracted bone, for both groups. After 4 months for implant integration, bridges were fabricated and secured to the implants with screws. Crestal bone levels were evaluated by radiographs through 1 year of function. Animals were killed after 1 year of loading for histologic evaluation. RESULTS: The vertical ridge augmentation averaged 8.8 +/- 1.0 mm after 10 weeks of healing after distraction. Analysis of variance indicated a significantly greater change from baseline for HA-coated implants and for distracted bone sites. Histologic examination showed that bone had formed between the distracted segments creating an augmented ridge. The average thickness of the labial cortex in the distraction gap was significantly thinner than the lingual cortex in distracted bone or the lingual and labial nondistracted cortical bone. The presence of a dental implant did not significantly affect cortical bone thickness. Serial sections showed that implants remained integrated and functional without soft tissue inflammation. CONCLUSION: Dental implants placed into alveolar ridges augmented with the technique of distraction osteogenesis were functional for the length of this study.

Alveolar Process↗

PubMed2002

Effects of distraction on muscle length: mechanisms involved in sarcomerogenesis.

Although a great deal of interest has been given to understanding the mechanisms involved in regulating the radial growth that occurs because of resistance training, much less has been given to studying the longitudinal growth of skeletal muscle that occurs because of passive stretch. The current authors provide a brief overview of key issues relevant to the longitudinal growth of skeletal muscle that occurs during distraction osteogenesis. Specifically, five key issues are addressed: (1) the pattern of sarcomerogenesis during distraction; (2) sarcomerogenesis and altered expression of sarcomeric and nonsarcomeric genes; (3) the satellite cell hypothesis; (4) mitogenic factors; and (5) new approaches for studying the longitudinal growth of skeletal muscle. A discussion is provided that revolves around the concept of a negative feedback loop. One of the most interesting issues to be resolved in muscle biology is the role of satellite cells in regulating the growth of skeletal muscle. Currently, it is not known whether satellite cell activation is a prerequisite for the longitudinal growth of skeletal muscle. Gene chip analyses provide a paradoxical view, showing that distraction osteogenesis results in the upregulation of a gene, GADD45, involved with growth arrest and deoxyribonucleic acid destruction.

Animals↗

PubMed2003

[Long-term effects and influence on facial structure of palatal distraction].

OBJECTIVE: The purpose of this study was to evaluate a new palatoplasty with persistent elastic distraction osteogenesis. METHODS: Twenty mongrel dog aged in 6 month were divided into two groups: the control (n = 10) and the experimental group (n = 10). The cleft palate model was made surgically in experimental dogs. The hard palate clefts were repaired with persistent elastic distraction osteogenesis. Then the animals were observed for an additional 12 weeks before sacrifice. Direct measurements was taken on dry skulls of the dogs and the data were analyzed statistically. RESULTS: For all experimental dogs, the clefts were closed after gradual distraction. No relapse and airway blocking occurred in observational period. There were no significant differences in the variables of facial length, height and width between the two groups (P > 0.05). The length of horizontal portion of hard palate in experimental group was significantly longer than that in the control (P < 0.01). CONCLUSION: There was no complication and disturbance on maxillofacial structure in repairing cleft palate with persistent elastic distraction osteogenesis. It is an effective and safe technique for repairing cleft palate in animal model.

Animals↗

PubMed2002

Correction of severe vertical maxillary excess with anterior open bite and transverse maxillary deficiency.

Patients requiring correction of large anterior open bites have historically been among the most challenging treatments for orthodontists. Adding to that fundamental challenge for the adult patient in this case was vertical maxillary excess, a severe transverse maxillary deficiency as well as an arch length inadequacy, even though the patient had prior orthodontic treatment. The prior orthodontist had included arch expansion and extracted four first bicuspids, which limited current treatment options. Various treatment modalities that have traditionally been used to correct transverse maxillary deficiency and the accompanying arch length inadequacy include extractions, labial and buccal dental tipping, segmental maxillary osteotomies, and rapid maxillary expansion with or without surgical assistance. Transverse maxillary distraction osteogenesis is a modification (ie, using a latency period and specific rate and rhythm of distraction) of the surgically assisted rapid maxillary expansion technique developed 25 years ago. This case demonstrates the relationship of transverse maxillary deficiency as well as vertical maxillary excess to apertognathia. Considerations regarding the use of segmental maxillary osteotomy vs transverse distraction osteogenesis are discussed. This case report illustrates the benefit of a team approach using transverse maxillary distraction osteogenesis, effective orthodontic mechanics, and orthognathic surgery to correct a severe dentofacial deformity.

Adolescent↗

PubMed2005

A comparison of synovial fluid pressure after immediate versus gradual mandibular advancement in the miniature pig.

PURPOSE: Mandibular advancement is a commonly performed surgical procedure for the treatment of mandibular hypoplasia. With the increased use of rigid fixation, there has been a decrease in the amount of relapse but an increase in the amount of force transmitted to the condyles. Gradual advancement of the mandible by distraction osteogenesis slowly overcomes the soft-tissue envelope and may decrease the amount of force exerted on the condyles. The purpose of this study was to develop an animal model to measure the magnitude of pressure associated with immediate versus gradual mandibular advancement. MATERIALS AND METHODS: A 2.0-mm pressure transducer was placed in the superior joint space in 2 miniature pigs. In the first animal, immediate advancement of the mandible with rigid fixation was performed. The synovial fluid hydrostatic pressures were measured prior to surgery and postoperatively. A second animal underwent gradual advancement with distraction osteogenesis. The synovial fluid hydrostatic pressures were measured prior to and after each activation of the distraction device. The condyles were examined radiographically and microscopically. RESULTS: The superior joint space fluid pressures increased and remained elevated over a 5-week period after immediate advancement. In the gradually advanced mandible, the pressures were elevated but returned to near baseline prior to the activation the following day. CONCLUSION: This animal model is useful to directly measure the pressure that is exerted on the condyle. This will allow further studies to compare methods for mandibular advancement. It is likely that gradual advancement of the mandible by distraction osteogenesis produces less force and causes less condylar resorption than large mandibular advancement stabilized with rigid fixation.

Animals↗