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PubMed1999

Distraction osteogenesis of the midface: a new implantable distraction device.

This report describes the use of a new implantable device for distraction osteogenesis of the maxilla in treatment of midface hypoplasia seen in craniofacial syndromes. The technique of distraction osteogenesis is a recent advance in plastic surgery for treatment of bone growth disorders. The device is totally implantable except for the activating pin and can provide up to 30 mm of total advancement. We will describe our surgical technique and distraction protocol, illustrated by a case report of the device successfully used in a child with Crouzon syndrome.

Child↗
PubMed1999

The role of transforming growth factor-beta, insulin-like growth factor I, and basic fibroblast growth factor in distraction osteogenesis of the mandible.

Distraction osteogenesis is a viable method for regenerating large amounts of bone. In contrast to fracture healing, the mode of bone formation in distraction osteogenesis is primarily intramembranous ossification. The basic biology of the process is still not well understood. The growth factor cascade is likely to play an important role in distraction. This study examines the growth factor cascade in a lengthened ovine mandible model. Twenty-four animals were divided into four groups with varying rates of distraction (1, 2, 3, and 4 mm/day). A unilateral distractor at the angle of the mandible was used. The mandibles were lengthened to 24 mm and fixed for a period of 5 weeks, after which the animals were killed. The sections were probed for transforming growth factor-beta, basic fibroblast growth factor, and insulin-like growth factor I. The growth factors studied were present in all four groups. Transforming growth factor-beta, basic fibroblast growth factor, and insulin-like growth factor I were present in both the bony matrix of the sections and the cytoplasm of the cells, osteoblasts, and a small number of mesenchymal cells. The sections obtained from groups distracted at faster rates showed stronger presence of the growth factors examined by more intense staining. In fracture healing, the localization of transforming growth factor-beta in stage I of healing corresponded with the precise region of intramembranous ossification in stage II. Diffuse presence of transforming growth factor-beta throughout the lengthened region corresponded with the process of intramembranous ossification observed in distraction. In fracture healing, insulin-like growth factor I and basic fibroblast growth factor have been shown to promote proliferation and differentiation of osteoblasts from precursor cells. The intense presence of insulin-like growth factor I and basic fibroblast growth factor in the distracted region may account for osteoblast proliferation and formation from precursor mesenchymal cells. Mechanical strain has been shown to increase the expression of transforming growth factor-beta and insulin-like growth factor I. Distraction may serve as a source of mechanical strain, which may explain, in part, the expression of these growth factors, particularly in the faster groups.

Animals↗
PubMed2001

Distraction osteogenesis of the craniofacial skeleton.

In summary, distraction osteogenesis is a safe and effective means of achieving bone lengthening. These techniques were originally applied to the long bones of the extremities; over the past 10 years they have been effectively applied to the bones of the craniofacial skeleton. The new bone regenerate that is observed after distraction osteogenesis is stable, and relapse rates after skeletal advancement are believed to be lower than with conventional osteotomy and bone graft techniques. There is considerable variability in distraction protocols employed in clinical practice, including differences in the types of devices used and in the rate, rhythm, latency, and period of consolidation for distraction osteogenesis. The greatest application for distraction osteogenesis in the craniofacial skeleton has been with mandible lengthening, for which there is presently a 10-year clinical experience. Midfacial advancement is a newer application of distraction osteogenesis, for which clinical experience has been accrued over the past 5 years. This latter experience indicates that distraction osteogenesis is a viable treatment option for lengthening of the hypoplastic mandible and midface. These techniques have advantages over conventional means of bone graft and rigid fixation because of the quality of the bone regenerate, the decrease in the long-term relapse rate of the advanced bone segments in both the mandible and the midface, and the simultaneous soft-tissue elongation that accompanies the distraction process. Distraction osteogenesis is particularly applicable to the correction of severe deformities of the mandible and midface in children with developmental hypoplasia and syndromic craniosynostosis. However, growth is an added variable in this patient population. The amount of overcorrection in lengthening of the hypoplastic bone required to compensate for continued growth discrepancy of the adjacent facial bones is difficult to predict. Therefore, the families of these patients should be informed that many children will require repeated operations at a later age as they reach skeletal maturity.

Child↗
PubMed2004

Preliminary investigation into the effects of electrical stimulation on mandibular distraction osteogenesis in goats.

Craniofacial distraction osteogenesis (DO) was found to be a procedure with low preoperative and postoperative morbidity. Direct current electrical stimulation is used clinically to treat different orthopaedic problems. It provided a significant increase in new-bone formation, and a higher mechanical strength of healing. The purpose of this study was to test the effect of electric current on distraction osteogenesis and to establish the best period to apply an electric current during the different distraction phases. Twelve healthy adult goats were subjected to a vertical osteotomy in the symphyseal area. A distraction device was fixed to the bone. Animals were divided into two groups, Group I (three goats) and group II (nine goats). In group I, the device was activated 1mm per day for 10 days; while in group II, the device was activated 1mm per day for 10 days with the application of direct electric current stimulation of 10 microA either during the first 3 days of latency in a continuous mode (ESL group), or during the first 3 days of the activation period in a continuous mode (ESA group); or during the first 3 days of the consolidation period in a continuous mode (ESC group). After the activation period was completed, the distraction device left in place for additional 15 days for bone consolidation in all animals. Animals were then sacrificed, the mandible was harvested, and the distracted areas were removed and processed for mechanical and histological studies. The results of this study suggested that direct current electrical stimulation display synergism on mandibular distraction when this stimulation applied to the distraction zone during activation or consolidation periods.

Analysis of Variance↗
PubMed1997

Distraction osteogenesis: application to dentofacial orthopedics.

Distraction osteogenesis is a surgical-orthopedic method for lengthening bone by separating or distracting a fracture callus. This technique has a long history in limb lengthening and has recently been used to lengthen mandibles and maxillae in human patients. Distraction osteogenesis represents a powerful method of producing unlimited quantities of living bone which can be formed along any plane of space. Because this method uses local host tissue, it offers many advantages over bone grafting. In the author's experience, large (10-22 mm) antero-posterior and vertical corrections of mandibles can be achieved using this technique. The purpose of this article is to review its biological basis and discuss recent clinical applications. This article reviews the history, theory, current management, and limitations of distraction osteogenesis in treating craniofacial anomalies.

Cephalometry↗
PubMed2003

Cost, operation and hospitalization times in distraction osteogenesis versus sagittal split osteotomy.

INTRODUCTION: Distraction osteogenesis in 'common' surgical orthodontics is mentioned as an alternative for conventional sagittal split osteotomy. After a 'learning curve' in the surgical skills of distraction, the two techniques can be compared concerning time and cost aspects. PATIENTS: Forty-seven patients (male n=28, female n=19, age 11.7-17.9 yr (mean 14.2) with an Angle's class II division 1malocclusion of skeletal mandibular origin were operated on using distraction osteogenesis and were compared with a second group of 21 patients (male n=4, female n=17, age 16-36yr (mean 22.8) who underwent bilateral sagittal split osteotomies in the same period in order to correct the same type of dysgnathia. METHOD: The first group of 47 patients was treated with intraorally placed bone-born distraction devices to correct mandibular deficiency following a standard protocol, with removal of the third molar tooth germs if present. The second group of 21 patients underwent standard sagittal split osteotomies to correct the mandibular deficiency. The costs of hospitalization, distraction devices and operation time were compared. RESULTS: In this study, distraction osteogenesis took on average more operative time (mean 37%), but 1 day less hospitalization than the bilateral sagittal split osteotomies. The surgical cost of distraction osteogenesis was 36% higher than the conventional sagittal split osteotomy. CONCLUSION: In this study, correcting Angle's class II deficiencies by means of distraction osteogenesis was shown not to be a time-saving procedure when compared with sagittal split osteotomy. Surgical costs were significantly higher using distraction, mainly due to the price of the distractors. Changes in hospital policies concerning hospital admission of adults and children and European legislation concerning re-usability of surgical instruments may balance the cost of both procedures.

Adolescent↗
PubMed2003

Expression of smooth muscle actin in cells involved in distraction osteogenesis in a rat model.

Distraction osteogenesis has proven to be of great value for the treatment of a variety of musculoskeletal problems. Little is still known, however, about the phenotypic changes in the cells participating in the bone formation process, induced by the procedure. Recent findings of the expression of a contractile muscle actin isoform, alpha-smooth muscle actin (SMA), in musculoskeletal connective tissue cells prompted this immunohistochemical study of the expression of SMA in cells participating in distraction osteogenesis in a rat model. The tissues within and adjacent to the distraction site could be distinguished histologically on the basis of cell morphology, density, and extracellular matrix make-up. The percentage of SMA-containing cells within each tissue zone was graded from 0 to 4. The majority of the cells in each of the zones stained positive for SMA within five days of the distraction period. The SMA-containing cells included those with elongated morphology in the center of the distraction site and the active osteoblasts on the surfaces of the newly forming bone. These finding warrant further investigation of the role of this contractile actin isoform in distraction osteogenesis and investigation of the effects of modulation of this actin isoform on the procedure.

Actins↗
PubMed2003

Predicting the outcome of distraction osteogenesis by 3-phase bone scintigraphy.

UNLABELLED: Distraction osteogenesis is an effective method for lengthening long bones and filling bone defects that result from bone resection. Insufficiency of bone consolidation in the distraction segment is problematic. In this study, we examined whether 3-phase bone scintigraphy can predict the outcome of distraction osteogenesis. We also investigated the effects of chemotherapy and surgical treatment on distraction osteogenesis. METHODS: We performed 3-phase bone scintigraphy on 60 patients (9 high-grade malignant bone tumors as group A, 11 low-grade malignant or benign tumors as group B, 40 nontumoral conditions as group C) with distraction osteogenesis at the lengthening phase of the long bones. By setting the region of interest on the distraction segment and contralateral normal area, we calculated the perfusion index (PI), the uptake ratio of the blood-pool image (BPR), and the uptake ratio of the delayed image (DR). Patients were classified into poor and good consolidation groups from the radiographic findings of the distraction segment. RESULTS: Good to fair correlations were obtained between the PI and BPR, the PI and DR, and the BPR and DR (r = 0.65, 0.45, and 0.57, respectively). The PI and BPR indicated no significant differences among group A-C (1.7 +/- 0.6, 2.1 +/- 0.7, and 1.8 +/- 0.8 in PI, respectively; 1.8 +/- 1.1, 1.9 +/- 0.5, and 2.0 +/- 0.7, in BPR, respectively). The DR of group A (2.4 +/- 1.2) was significantly lower than that of group B (6.3 +/- 1.8; P = 0.001) and group C (5.9 +/- 2.8; P < 0.001). Eleven patients were classified in the poor consolidation group. The other 49 patients showed good consolidation. The poor consolidation group showed lower values in all indices obtained by 3-phase bone scintigraphy than the good consolidation group. The optimal cutoff levels, sensitivity, specificity, and accuracy of each index for detection of patients with poor consolidation were as follows: 1.1, 36%, 90%, and 80% in the PI, respectively; 1.2, 55%, 94%, and 87% in the BPR, respectively; and 2.2, 82%, 96%, and 93% in the DR, respectively. CONCLUSION: Three-phase bone scintigraphy is a promising method for the assessment of distraction osteogenesis. The delayed image of 3-phase bone scintigraphy, especially, is an excellent modality for predicting the outcome of distraction osteogenesis.

Adolescent↗
PubMed1997

Rat model of distraction osteogenesis.

Prior studies of distraction osteogenesis in dog and rabbit models have shown predominantly intramembranous bone formation. Other models of fracture healing normally display mixtures of both endochondral and intramembranous bone formation. We have established a rat model of tibial lengthening that reliably reproduces the pattern of zonal osteogenesis previously observed in dog and rabbit models. A distraction rate of 0.25 mm twice a day with a 0-day latency period produced intramembranous bone with zones of progressive mineralization from collagen. With this protocol, rats bridged the distraction gap with a 25% increase in the tibial bone length. After 20 days of distraction and 50 days of consolidation, the three-point bending stiffness, as a percentage of the contralateral control, reached a level equivalent to that measured in the canine model for a 15% lengthening (28-day distraction and 84-day consolidation). Radiodensitometric analysis of the regenerate bones measured 97% of the unaffected contralateral tibial densities, and mineral analyses demonstrated that calcium and phosphorus levels in the regenerate bone reached 78% of contralateral tibial levels by day 70. We concluded that a rat model of distraction osteogenesis will be useful for a wide range of studies involving rapid intramembranous bone formation.

Animals↗
PubMed1997

Management of severe maxillary deficiency in childhood and adolescence through distraction osteogenesis with an external, adjustable, rigid distraction device.

We present our technique for maxillary distraction osteogenesis in patients with severe maxillary hypoplasia. With the use of an external, adjustable, rigid distraction device, we can now treat patients with severe maxillary hypoplasia with a precise and controlled distraction process, obtaining predictable results. This technique has allowed us to treat patients in all age groups. In this report we review our indications for maxillary distraction and describe our technique using an external, adjustable, rigid midface distraction device.

Adolescent↗
PubMed2001

Distraction osteogenesis of the craniofacial skeleton.

Distraction osteogenesis is becoming the treatment of choice for the surgical correction of hypoplasias of the craniofacial skeleton. Its principle is based on the studies of Ilizarov, who showed that osteogenesis can be induced if bone is expanded (distracted) along its long axis at the rate of 1 mm per day. This process induces new bone formation along the vector of pull without requiring the use of a bone graft. The technique also provides the added benefit of expanding the overlying soft tissues, which are frequently deficient in these patients. This article reviews the authors' 11-year clinical and research experience with mandibular distraction osteogenesis. It highlights the indications and contraindications of the technique and emphasizes the critical role that basic science research has played in its evolution.

Aging↗
PubMed2005

Unilateral mandibular widening with distraction osteogenesis.

Mandibular widening with distraction osteogenesis (DO) has been shown to be an acceptable and stable treatment modality. Mandibular widening with DO is useful in relieving crowding and for restoring a rotated mandibular arch segment to its original condition. This is especially true when a patient has a unilateral medial displacement of the proximal segment of the mandible or a unilateral Brodie bite. This case report shows the application of mandibular widening with DO for skeletal reconstruction and prosthodontic preparation in a patient with unilateral medial displacement of the proximal segment of the mandible. The design of the osteotomy line and the placement of the distractor must be taken into consideration in a detailed procedure for unilateral mandibular widening of the mandible.

Adult↗
PubMed2000

Craniofacial distraction osteogenesis en bloc.

Bone distraction of the superior and medial thirds of the craniofacial skeleton en bloc, avoiding a frontal craniectomy is presented. We applied this procedure in eight patients who were more than 5 years old with different types of craniofacial synostosis and who had not received previous treatment, and with a normal frontal shape. During monobloc advancement, major complications were encountered in older patients, especially the impossibility of the brain to expand rapidly to fill the retrofrontal dead space. Distraction osteogenesis of the craniofacial skeleton en bloc (without craniectomy) is feasible. Miniplates and screws are avoided as well as the possibility of frontal relapse or fractures of the frontozygomatic region. The patients did not need skull vault remodeling, except for a small cranioplasty at the bregma zone. The results obtained were satisfactory and stable at the time. This procedure avoids any kind of osteosynthesis, there is no extradural dead space, the operative time is brief, and blood loss is minimal. The inconvenience is the necessity of a second operation to remove the distractor.

Acrocephalosyndactylia↗
PubMedDate not supplied

Treatment of brachymetatarsia by distraction osteogenesis.

Metatarsal lengthening by distraction osteogenesis was performed on 17 brachymetatarsia patients with 39 metatarsal bones. To lengthen the first metatarsal in an attempt to prevent development of varus deformity of the hindfoot after lengthening, horizontal lengthening in the anterior direction was performed rather than lengthening through the anatomical axis. In addition, care was taken to ensure that the fourth metatarsal bone screw did not interpose with the fifth extensor tendon during the fourth metatarsal lengthening. Lengthening was successful except in 1 case with mean lengthening of 19.5 mm (48.8%) for the first metatarsal and 17.1 mm (36.2%) for the fourth metatarsal. Because of joint stiffness, plantar capsulotomy was performed on 7 cases, 6 of which had been previously operated on bilaterally. Varus deformity of the hindfoot after the first metatarsal lengthening and entrapment of the fifth extensor tendon after the fourth metatarsal lengthening was not detected in any case.

Adolescent↗
PubMed2002

[Stimulation and evaluation on maxillary distraction osteogenesis using CASSOS 2001].

OBJECTIVE: To simulate maxillary distraction osteogenesis and evaluate the change of soft and hard tissue before and after treatment, using Computer-Assisted Simulation System for Orthognathic Surgery( CASSOS 2001). METHODS: A fourteen-year-old boy with severe maxillary hypoplasia, due to unilateral cleft lip and palate, was analysed by cephalometric analysis. The simulations of maxillary distraction osteogenesis (Le Fort I osteotomy and Le Fort II osteotomy) were re-analysed. After the treatment, cephalometric analysis was preformed again. The data were compared. RESULTS: The maxillary hypoplasia was well treated using maxillary distraction osteogenesis; Compared with Le fort I osteotomy, more satisfactory results can be obtained by Le fort I distraction osteogenesis. CONCLUSION: Maxillary distraction osteogenesis is a better way to treat severe maxillary hypoplasia with operated CLP than maxillary osteotomy. CASSOS 2001 can help surgeons and patients on simulation and evaluation of maxillary distraction osteogenesis, and on decision of treatment plan.

English Abstract↗
PubMed2002

Distraction osteogenesis of the mandible: evaluation of callus distraction by B-scan ultrasonography.

INTRODUCTION: Distraction osteogenesis is a new and reliable technique for lengthening of hard and soft tissue in cranio-maxillofacial surgery. Since its first applications, X-rays were often the preferred diagnostic method to monitor this treatment. Apart from adding an additional radiation dose, analysis cannot detect and follow the osteogenic process in the distraction gap on the one hand, nor can it evaluate the soft tissue around the distracted area. In this paper, the authors report their experience with B-scan imaging to control mandibular distraction and to overcome the shortcomings of X-rays analysis. METHOD: Comparison of B-scanning with the traditional X-ray methods was performed in 12 patients. RESULTS: B-scan evaluation appeared to be a precise technique in monitoring the different phases of distraction. It is easy to repeat whenever necessary. Early and late complications of soft tissue healing, movements of the bone segment, as well as the osteogenesis were easily detectable. CONCLUSION: In the authors' opinion B-scan evaluation can play an important role in monitoring distraction osteogenesis.

Adult↗
PubMed2000

[Distraction osteogenesis in maxillofacial surgery].

With distraction osteogenesis (DOG) formation of new bone is initiated by gradual separation of osteotomized bone fragments. Both external and internal distraction devices are available. Since its first application in craniomaxillofacial surgery in the early nineties, developments in distraction osteogenesis have been tremendous. Important advantages of this technique are: lack of a donorsite and its associated morbidity; increase of the volume of the soft tissue envelop; less surgical trauma compared to conventional craniomaxillofacial procedures; and the usability of the technique in growing individuals. Disadvantages of DOG are: the sofar limited experience and follow-up in craniomaxillofacial surgery; and the unknown influences on growth. The technique will gradually find its niche and the general dentist will therefore be increasingly confronted with its specific indications. In this paper the general principles of DOG and a number of indications in craniomaxillofacial surgery are discussed.

Humans↗