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PubMed2004

Maxillary distraction resulting in facial advancement at Le Fort III level in cleft lip and palate patients: a report of two cases.

An 18-year-old female and a 14-year-old male who had previously received surgery for primary repair of a nonsyndromic cleft lip and palate (including alveolar defect bone grafting) unintentionally developed facial advancement at the Le Fort III level after surgical correction of their maxillary hypoplasia. The Le Fort I osteotomy, originally performed for their maxillary dentoalveolar hypoplasia, was an incomplete osteotomy. It was performed without down-fracture, leaving the pterygomaxillary and septal junctions intact. The gradual advancement of the maxilla during distraction osteogenesis was planned to correct the hypoplastic maxilla, and also prevent subsequent hypernasality; however, during the distraction procedure by means of a rigid external device both patients developed an unintentional facial advancement at the Le Fort III level.

Adolescent↗
PubMed2007

Transplantation of osteoblast-like cells to the distracted callus in the rabbit mandible.

BACKGROUND: The purpose of this study was to investigate whether injections of marrow-derived mesenchymal progenitor cells could be used to facilitate new bone formation during distraction osteogenesis. METHODS: Fifteen New Zealand rabbits underwent bilateral osteotomy. After a 1-week latency period, bone distraction was activated at a rate of 2.0 mm/day for 5 days. The marrow-derived mesenchymal progenitor cells derived from the ilium marrow were cultured to a population of 10 in 0.5 ml and then unilaterally transplanted to the gap of distracted callus immediately after distraction had been terminated. Rabbits were killed at 2, 4, and 6 weeks after completion of bone lengthening. The distracted areas were harvested and evaluated by histologic, histomorphometric, radiographic, and scanning electron microscopic analysis. Bone mineral density in the lengthened callus was evaluated using dual-energy x-ray absorptiometry. RESULTS: Radiographic evaluation indicated a significant increase in bony union of the distraction regenerate in the experimental side compared with the control side. Corresponding to the radiographic findings, the histologic examination showed an earlier and more intensive bone formation in the experimental side after 2, 4, and 6 weeks compared with the control side. Larger chondroid islands were found evident in distracted bone of the control side than in the experimental side. CONCLUSIONS: The results show that transplantation of osteoblast-like cells promotes maturity of the distracted callus, as observed on the second and fourth weeks after lengthening. The method appears promising as a means of shortening the consolidation period of osteodistraction and decreasing complications during bone lengthening.

Animals↗
PubMed2002

Minimally invasive Le Fort III distraction.

Recent applications of distraction osteogenesis to the Le Fort III osteotomy in patients with craniofacial dysostosis have proven promising (1-3). Distraction has allowed the midfacial segment to be brought further forward and maintained in position with greater stability when compared with the standard technique of intraoperative advancement. Because no bone grafts or plates must be placed, access incisions are necessary only for performance of the osteotomy. In an effort to minimize the morbidity of the procedure, we have begun performing the Le Fort III osteotomy without the coronal incision. Instead, the nasofrontal junction is approached using the medial aspect of an upper blepharoplasty incision. A lower eyelid and gingivobuccal sulcus incision are also used to complete the osteotomy. This technique has resulted in a shorter operative time and decreased blood loss when compared with the Le Fort III distraction procedure using the standard coronal incision.

Adolescent↗
PubMed2000

[Continuous bone distraction with the help of a microhydraulic cylinder].

Distraction osteogenesis of the mandible is one treatment option in mandibular hypoplasia. Usually, a non-continuous distraction mode is applied. The aim of the present study was to establish continuous bone distraction using a microhydraulic cylinder. Using a submandibular approach, the mandible was dissected subperiostally on one side in four mini-pigs; corticotomy was performed and the microhydraulic cylinder fixed with two bicortical screws. The hydraulic tube was connected with an automatic hydropneumatic injector system. Following 7 days at rest, a continuous distraction of 1.5 mm per day was performed for 14 days. After 2 and 4 weeks postoperatively, the animals were killed and X-rays taken. The mandible was then removed en bloc and microscopic evaluation of the sections was performed. The microhydraulic cylinder was easy to apply and to handle. The continuous stimulus did induce direct mineralisation of longitudinal oriented collagenous fibre bundles. Bony regeneration seems to be accelerated, which might reduce the postoperatively stabilizing phase.

Animals↗
PubMed2005

Prevention of halo pin complications in post-cranioplasty patients.

INTRODUCTION: Distraction Osteogenesis has been successfully implemented in the treatment of maxillary hypoplasia. By using the Rigid External Distraction device (RED) the maxilla can be advanced without the need for bone grafts, providing more stability to the repositioned maxilla. BACKGROUND: The introduction of the RED system in craniofacial surgery has given rise to previously unseen problems. AIM: To provide a set of protocol improvements that might prevent the intracranial pin migration seen at the removal of a RED-II in one patient. CONCLUSIONS: Although the RED device has been shown to achieve good clinical results, there are some disadvantages to the system. There is a high incidence of pin tract infections - leading to loosening of the pins and loss of rigidity. Also, the external ring is prone to traumatic injury. Furthermore, the positioning of the pins can be difficult in thin bone. The improvements used in our protocol might prevent this complication.

Adolescent↗
PubMed2005

Duration of orthodontic treatment and mandibular lengthening by means of distraction or bilateral sagittal split osteotomy in patients with Angle Class II malocclusions.

BACKGROUND: The purpose of this study was to investigate the duration of treatment of patients with skeletal Angle Class II malocclusions treated with orthodontic appliances and surgical lengthening of the mandible to close residual overjets. METHODS: In this retrospective study, the patients were divided into 3 groups. Group A consisted of 10 patients (5 boys, 5 girls; mean age, 10.11 years; range, 9.1-13.9 years at the beginning of treatment) who were treated with a headgear-activator, fixed appliances, and intraoral osteodistraction of the mandible. Group B consisted of 19 patients (10 boys, 9 girls; mean age, 12.3 years; range, 9.6-16.1 years) treated with fixed appliances and intraoral distraction. In group C, 13 patients (4 men, 9 women; mean age, 27.3 years; range, 12.11-40.7 years) were treated with fixed appliances and bilateral sagittal split osteotomy (BSSO). RESULTS: In patients treated with orthodontic appliances and surgical lengthening of the mandible, treatment time was influenced by the appliances and the surgical technique used. Patients treated with a headgear-activator, fixed appliances, and intraoral distraction osteogenesis (group A) needed significantly more treatment time than patients treated with fixed orthodontic appliances and intraoral distraction (group B) or fixed appliances and BSSO (group C). Duration of treatment with intraoral mandibular distraction (group B) was significantly (P < .05) shorter compared with mandibular lengthening with BSSO (group C). However, no definitive conclusions can be drawn, because of the retrospective study design. CONCLUSIONS: The best time and the best surgical procedure for correcting mandibular length have yet to be determined, and a prospective randomized trial is recommended.

Adolescent↗
PubMed2004

Prototype testing for a new bioabsorbable Le Fort III distraction device: a pilot study.

PURPOSE: The goal of the study was to design and test prototypes for a new, internal resorbable Le Fort III distractor in the minipig model. MATERIALS AND METHODS: Le Fort III osteotomies were performed on 3 juvenile minipigs, followed by implantation of the bioabsorbable distractors. After a 5-day latency period, the distraction progressed at a rate of 1 mm/day in 2 equal increments for 12 days. This was followed by a 6-week consolidation phase. Cephalometric radiographs were taken postoperatively, on completion of distraction and after the consolidation phase, to evaluate the amount of distraction that was obtained. Necropsy was performed at the completion of each experiment. RESULTS: The first minipig was sacrificed at the end of the distraction period because of device failure. On necropsy, it was noted that the anterior footplate on either side had failed. The second minipig was sacrificed during the latency period because of severe pneumonia. On necropsy, it was noted that none of the footplates had failed but that the distraction barrels on either side had become dislodged from the anterior bioabsorbable footplates. The third minipig was sacrificed at the end of the distraction period because of device failure. On necropsy, it was noted that the posterior bioabsorbable footplates on either side were fractured across the posterior screw lines. CONCLUSIONS: The bioabsorbable devices evaluated in this study could not withstand the forces generated during distraction osteogenesis in the minipig model. Experience with the prototypes may help in designing internal bioresorbable Le Fort III distraction devices.

Absorbable Implants↗
PubMed2003

Le Fort III osteotomy: a new internal positioned distractor.

PURPOSE: The treatment of midfacial retrusion, due to congenital midfacial hypoplasia or trauma, is a challenging problem. Conventional Le Fort III osteotomies, with the surgical mobilisation of the entire midface, offers one solution. Distraction osteogenesis has become an accepted, and often preferred, technique for the treatment of severe midfacial hypoplasia. Existing distraction devices have several disadvantages. To overcome some of these disadvantages, an internal and temporal positioned distraction device was developed. PATIENTS AND METHODS: The new, internal positioned distractor device was used in 5 patients (age range, 8 to 15 years). Nine distractors were used in 4 patients with midfacial retrusion and 1 patient with hemifacial microsomia. RESULTS: The preoperative planned position of the osteotomized Le Fort III segment was obtained without any complications in all cases. Midface advancement, measured as the anterior displacement of the infraorbital rim, ranged from 14 to 20 mm. The distractor was almost invisible and did not disturb daily activities of the patient. Activation of the distractor was performed by rotation of a small lateral activation rod. CONCLUSION: These preliminary results encourage the further use of the new distractor device in a larger series of patients.

Adolescent↗
PubMed2001

Radiographic evaluation of bone formation in the pterygoid region after maxillary distraction with a rigid external distraction (RED) device.

In recent years, distraction osteogenesis has been used to correct skeletal disharmonies in the craniofacial region including the mandible and maxilla. Rigid external distraction has been used successfully to correct severe maxillary skeletal discrepancies. However, the characteristics of the newly formed bone have not been studied. A modified tomogram technique was used to analyze the radiological characteristics of the bone generated after maxillary advancement with rigid external distraction. The newly developed protocol may assist the clinician to evaluate the distracted area and to determine the length of stabilization required after active treatment with rigid external distraction.

Adolescent↗
PubMed2004

Histological changes in the temporomandibular joint in rabbits depending on the extent of mandibular lengthening by osteodistraction.

We studied the histological changes in the temporomandibular joint (TMJ) after unilateral mandibular distraction osteogenesis in rabbits. Eight rabbits were used, two of which served as controls and the other six had distraction of the left mandibular body after a latency period of 7 days at a rate of 0.5mm a day for a total of 2mm (n = 2), 3.5mm (n = 2), and 5mm (n = 2) of distraction. After a 14-day consolidation period, TMJs from both sides were harvested and prepared for histological examination under an optical microscope using haematoxylin and eosin stain. We found no degenerative or inflammatory changes in either TMJ in any of the groups. Endochondral ossification in the condyle was greater on the opposite side in the experimental group than in the condyles of the control group. Endochondral ossification was active in the 3.5-mm group.

Animals↗
PubMed2002

The floating bone technique of the vertical ramus in hemifacial microsomia: case report.

This article describes a case in which distraction osteogenesis of the vertical ramus of the mandible was used for a young woman with hemifacial microsomia. Failure of distraction occurred because of the wrong vector of distraction. The floating bone technique was applied to the vertical ramus and was used to correct the malocclusion and to recover the height of the vertical ramus. Complete skeletal correction of the asymmetry was obtained, with excellent esthetic results. The case shows that the floating bone technique is a valid method to help the surgeon in the management of malocclusion after distraction and also in cases of failure of distraction. The floating bone is possible on both the vertical ramus and on the horizontal ramus.

Adolescent↗
PubMed2004

Correction of facial deformity using a Red III device in a patient with Antley-Bixler syndrome.

Antley-Bixler syndrome was first described in 1975 and to date at least 44 cases have been reported. In addition to brachycephaly, this syndrome is associated with midface hypoplasia, bilateral radiohumeral synostosis, multiple joint contractures, long bone fractures, dysplastic ears, "pear shaped" nose, and occasionally urogenital or cardiac defects. The authors report a case in a 23-year-old man with severe midface deficiency treated using distraction osteogenesis. A modified Le Fort III osteotomy was performed, and nasal subunit and remaining Le Fort III segment was distracted separately. The classic RED II design was found to be insufficient, so the authors added an extra horizontal bar to the system and converted it to a RED III design. Midface advancement was 11 mm from the porion to the orbitale and 31 mm at point A. Nasal advancement at the nasal root level was 5 mm. There were no complications, and at 4 months after surgery, advancement was stable without any relapse.

Abnormalities, Multiple↗
PubMed2003

Lengthening of the reconstructed mandible using extraoral distraction devices: report of five cases.

Fibular and scapular osteocutaneous free-tissue transfer represents the workhorse procedure in the reconstruction of large oromandibular defects. However, transplanted bone segments for mandibular reconstruction may be too short for a correct interarch alignment, which is a prerequisite for further functional rehabilitation. Extraoral distraction osteogenesis was performed in the neomandible of five patients after tumor resection following neoadjuvant radiotherapy-chemotherapy. The neomandible was distracted bilaterally in two patients and unilaterally in three patients. Gradual distraction was applied at a rate of 0.5 mm twice a day after osteotomy in the region of vascularized fibular and scapular reconstruction. An average sagittal bone gain of 11 mm was achieved following active distraction. In three patients, the distraction procedure rendered good results with full compensation of the deficit; in one patient, the sagittal bone gain did not compensate for a lateral deviation of the mandible; and in another patient, the fixation pins loosened and had to be reaffixed. Osteodistraction is a treatment option in patients in whom vascularized bone grafts have been used for mandibular reconstruction, but due to contractures or lack of hard and soft tissues, no satisfactory interarch alignment could be achieved. Distraction procedures in irradiated and reconstructed neomandibles bear a higher risk of failure and complications than those in nonirradiated tissues. A correct and stable intermaxillary relation always has to be attempted in the first surgical approach, as osteodistraction cannot be suggested as a routine procedure in this special group of patients.

Bone Transplantation↗
PubMed2004

Cellular and molecular characterization of a murine non-union model.

PURPOSE: We have developed a method to study the molecular and cellular events underlying delayed skeletal repair in a model that utilizes distraction osteogenesis. METHODS: The clinical states of delayed union and non-union were reproduced in this murine model by altering distraction parameters such as the inclusion and exclusion of a latency phase and variations in the rate and rhythm of distraction. Radiographic, cellular, and molecular analyses were performed on the distraction tissues. RESULTS: Eliminating the latency period delayed bony union, but did not appreciably alter the extent of platelet endothelial cell adhesion marker (PECAM) immunostaining. Following elimination of a latency phase and a threefold increase in the rate of distraction, there was a further delay in bone regeneration and a higher rate of non-union (60%). Instead of bone, the distraction gap was comprised of adipose or fibrous tissue. Once again, despite the rigorous distraction protocol, we detected equivalent PECAM staining within the distraction gap. In a minority of cases, cartilage and osseous tissues occupied the distraction gap likely by a prolonged process of endochondral ossification. CONCLUSIONS: Here, we have altered the mechanical environment in such a way to reproducibly create delays in skeletal regeneration. These delays in skeletal tissue regeneration appear to develop even in the presence of endothelial cells, which suggests that mechanisms other than a disruption to the vascular network can account for some cases of non-union.

Animals↗
PubMed2002

LeFort I soft tissue distraction: a hybrid technique.

Distraction osteogenesis of the craniofacial skeleton has greatly enhanced traditional osteotomies and bone grafting techniques. The obvious drawbacks to an external distraction device are visibility and awkwardness. A hybrid technique of maxillary distraction for soft tissue expansion and formation of regenerate, combined with rigid internal fixation, is proposed. This technique permits maxillary advancement that may be unattainable by traditional methods and obviates the extended use of external hardware during latency and consolidation of the regenerate. It also allows for optimization of the dental occlusion. The study group was composed of five patients with severe skeletal class III malocclusion who had combined maxillary distraction followed by rigid internal fixation. The average age at the time of LeFort osteotomy was 17 years, with a range of 13 to 19 years. The latency period ranged from 1 to 5 days, and distraction was done at the rate of 1 mm/d in all patients. After the proposed advancement was attained, all patients had reoperation, consisting of distractor removal, optimized interdental relationships with intermaxillary fixation, and placement of rigid internal fixation. The average anterior-posterior maxillary advancement was 11.6 mm, with a range of 10 to 13 mm. Lateral cephalograms and clinical examination showed no relapse at an average follow-up of 25 months, with a range of 5 to 40 months.

Adolescent↗
PubMed2006

Combined push-pull distraction for correction of syndromic midfacial hypoplasia.

PURPOSE: Gradual midfacial advancement, applying the principle of distraction osteogenesis, reduces the restriction of the soft tissues and results in bony consolidation without need for grafting. The midface can be distracted by either pushing it forward, using semiburied devices, or pulling it forward by a rigid external device. For each method there are inherent technical problems, such as controlling the vector of movement, symmetry of advancement, and differential movement of the upper/lower face. We have used a combination of the 2 methods, called "push-pull," in an effort to control the distraction process. The purpose of this paper is to describe our push-pull distraction technique and summarize our early experience. MATERIALS AND METHODS: Ten patients (5 males and 5 females) with a mean age of 11 years 2 months underwent midfacial advancement using push-pull distraction. Two orthodontists, blinded for landmark identification, traced preoperative and postoperative cephalograms and determined linear and angular measurements of midfacial position. A Student t test was used to assess differences between the cephalometric measures on the 2 radiographs. Interexaminer reliability was calculated by an intraclass correlation coefficient. RESULTS: Postdistraction cephalograms were taken a mean of 10 months (range, 3 to 20 months) after removal of the devices. Patients exhibited improvement at all levels of the midface after distraction. There was a statistically significant sagittal advancement from the infraorbital rim to dentoalveolus. The central midface was sufficiently advanced as shown by an improved convexity, nasolabial angle, and upper labial protrusion. There were no significant differences between examiners for any of the measurements in this study. CONCLUSIONS: Push-pull distraction permits 1) equal movement at both the upper and lower facial levels, 2) advancement of the central midface, and 3) symmetric movement of the zygomaticomaxillary complexes. This method also provides a backup, in case one device malfunctions. In combination, the advantages of each device are additive; whereas the weaknesses are not. The push-pull technique is a practical method for midfacial distraction until a better single device is fabricated.

Acrocephalosyndactylia↗
PubMed1999

Histological examination of regenerated bone through craniofacial bone distraction in clinical studies.

The process of bone formation by distraction osteogenesis of the craniofacial bone has been studied in animals. To our knowledge there are no published findings in which histological examination of craniofacial distraction in humans has been reported. Specimens were obtained from 10 patients who underwent craniofacial distraction: 2 patients who underwent mandibular distraction, 7 patients who underwent midface distraction, and 1 patient who underwent nasal bone distraction. These specimens were examined histologically. The results revealed that 8 of 10 patients exhibited new bone formation. No cartilaginous callus formation was observed in any of the specimens, which strongly suggests that new bone was produced by intramembranous ossification during human craniofacial bone distraction.

Adolescent↗
PubMed2005

Long-term results in maxillary deficiency using intraoral devices.

Cleft lip and palate patients often present maxillary retrusion and class III malocclusion after cleft repair. Maxillary distraction is a technique that can provide simultaneous skeletal advancement and expansion of soft tissue. Twelve patients with cleft maxillary deficiency due to cleft lip and palate were treated by Le Fort I osteotomy and two intraoral distraction devices that were activated after 4 days of latency period, 1mm per day on both sides. Long-term clinical and cephalometric evaluation of one and two years demonstrate stable results concerning the skeletal, dental and soft tissue relations. In this paper we discuss the advantages of distraction osteogenesis as a method for treatment of maxillary deficiency in cleft patients in terms of stability and relapse. The indications for maxillary distraction: (1) Moderate and severe retrusion that needs large advancement as in cleft lip and palate patients. (2) Forward and downward lengthening of the maxilla with no need for intermediate bone graft. (3) Growing patients. In conclusion, maxillary distraction in moderate or severe retrusion, as in cleft patients offers marked maxillary advancement with long-term stability.

Adolescent↗