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PubMed1999

Advances in congenital craniofacial surgery.

Surgery for the correction of craniofacial anomalies has come a long way since its beginnings more than three decades ago. Throughout this period numerous developments have occurred in diagnosis and management, as well as a better understanding of the etiology of craniofacial anomalies. Significant technological advancements in imaging have allowed for more precise diagnosis and surgical planning. Quantitative analysis techniques have been developed allowing for more precise results analysis. Nonsurgical management techniques have improved, as has the understanding of the proper utilization of nonsurgical treatment. Most nonsynostotic cases of head shape abnormality can be successfully managed nonsurgically. Improvements in surgical management include ways of diminishing the need for transfusions. Operative technical refinements also allow for improved results. The discovery of intracranial migration of rigid fixation hardware has led to decreased utilization of the metallic implants. Bone cements and absorbable plating systems promise further enhancements. Distraction osseogenesis allows skeletal changes to be made gradually reducing risks. Finally, the etiologies of craniosynostosis are being elucidated and promise to lead to more elegant management, reducing or alleviating the need for surgery. Genetic manipulation may eliminate many of these problems.

Bone Plates↗
PubMed2001

Quantitative changes in spinal canal dimensions using interbody distraction for spondylolisthesis.

STUDY DESIGN: An experimental study was performed using cadaveric lumbar spines to evaluate the effect of anteriorly or laterally placed interbody distraction implants on the alteration of spinal canal and neuroforaminal dimensions. OBJECTIVES: To quantify changes in the spinal canal and neuroforaminal dimensions using interbody fusion devices inserted at various configurations in cadaveric lumbar spines exhibiting degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: Although several clinical studies have demonstrated successful treatment of degenerative spondylolisthesis with anterior interbody fusion, no study has shown the role of interbody distraction in improving lumbar spinal canal and foraminal stenosis. METHODS: Five fresh cadaver lumbar spines exhibiting a degenerative spondylolisthesis or retrospondylolisthesis were used for the study. Computed tomography scans of each specimen and a silicon mold of the left intervertebral foramens were repeated in a consistent manner after pure compressive load (150 lb) was applied to simulate physiologic load (intact case), after two BAK (Sulzer SpineTech Inc., Minneapolis, MN) distraction plugs were anteriorly inserted into the intervertebral disc space (anterior distraction cases), and after one long BAK cage was laterally inserted from the left side (lateral distraction case). The cross-sectional area of the spinal canal was measured from computed tomography images using National Institutes of Health image software (Bethesda, MD). The spinal canal volume was calculated using the cross-sectional area and total scan thickness. Left intervertebral foraminal volumes were calculated from the weight of the silicon mold injected into the foramen. Descriptive statistics and a Student's t test were used to detect statistical differences in the spinal canal and neuroforaminal volumes before and after interbody distraction. RESULTS: The cross-sectional canal area was significantly increased after anterior distraction (35.11%) and lateral distraction (33.14%). The spinal canal volume was markedly increased with anterior distraction (19.92%) and lateral distraction (21.96%). Left foraminal volume was also enhanced by 40.25% for anterior distraction and 41.03% for lateral distraction. CONCLUSIONS: Interbody distraction either by anteriorly inserted plugs or laterally inserted threaded cagescan immediately improve the narrowed canal area and increase spinal canal, as well as foraminal volume for lumbar degenerative spondylolisthesis or retro- spondylolisthesis.

Anthropometry↗
PubMed2006

Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents.

BACKGROUND: Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results. METHODS: Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees. Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients. RESULTS: The mean preoperative arc of total elbow motion was 37 degrees. The mean pronation was 46 degrees, and the mean supination was 56 degrees. After a mean duration of follow-up of thirty-four months, all patients but two had achieved a functional arc of motion of 100 degrees. The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration. CONCLUSIONS: Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.

Adolescent↗
PubMed1999

Distraction of scarred soft tissue before secondary bone grafting. A case report.

Mandibular distraction was performed to restore oral function in a 52-year-old man with tongue cancer, in whom a mandibular fracture developed after marginal resection of the mandible. The fracture caused the mandibular dental arch to be shorter than the maxillary arch. An external fixation device was attached to the collapsed mandible. The mandibular soft tissue was expanded by 32 mm. After gradual distraction, a vascularized iliac bone graft was transferred to the lengthened space. Subsequently, vestibuloplasty was performed and implants were inserted. A normal appearance, acceptable occlusion and satisfactory oral function were achieved.

Bone Transplantation↗
PubMedDate not supplied

Anteroinferior distraction of the atrophic subtotal maxillary alveolus for implant placement: a case report.

Most reports on alveolar distraction have been related to vertical distraction in the mandible and the maxilla. There have been few reports on horizontal or oblique alveolar distraction. A case of an atrophic subtotal maxillary alveolus distracted 10 mm anteriorly and 5 mm vertically, followed by the placement of 9 implants, is presented. A healthy, 55-year-old woman presented with a chief complaint of mobility of all maxillary teeth. All remaining 11 teeth except the maxillary left second molar were diagnosed as being involved with advanced marginal periodontitis, and were considered hopeless and subsequently extracted. Three months after extraction, a horizontal osteotomy was performed with a bone saw between the bilateral second premolar regions, extending vertically distal to the second premolars, without involving the maxillary sinuses. After confirming mobility of the alveolar bone, a distraction device was seated with titanium miniscrews and adhesive resin cement over the hard palate. After a 7-day waiting period, the maxillary alveolus was distracted anteroinferiorly 0.25 mm twice a day for 25 consecutive days. The distraction process was completed uneventfully. Postdistraction computed tomography demonstrated that the maxillary alveolus was adequately distracted to place implants in an ideal position. Nine endosseous implants were placed 4 months after seating the distraction device. All implants had good primary stability and were submerged. All implants osseointegrated, although 2 anterior implants were replaced due to disintegration resulting from transmucosal overloading of the interim removable prosthesis. No significant marginal bone resorption was seen around the implants 16 months after implant placement. It was concluded that alveolar distraction can be very useful for augmenting the atrophic alveolus, not only vertically but also horizontally or obliquely.

Alveolar Ridge Augmentation↗
PubMed1998

[Modified Krukenberg-plasty with callus distraction of the stump and complete skin closure of both forearm branches].

In 1917, Hermann Krukenberg first reported on the conversion of a forearm stump into tongs by separating the ulna and radius in a bilateral forearm amputee. Up to now, this technique still has its indication in patients with bilateral loss of the hand or forearm. The main problem is still the coverage of both forearm branches with sensitive skin, especially when the muscles are preserved for surface management and strength. The two case reports of bilateral amputation injuries of the upper extremities illustrate our modification of the Krukenberg procedure. First, callus distraction of the short forearm stump by an external fixator was used in one case. After implantation of tissue expanders, enough sensitive skin was gained to resurface both arms of the Krukenberg forearm during a second procedure in both patients nearly completely.

Adult↗
PubMed1998

Callus formation in the humerus compared with the femur and tibia during limb lengthening.

We investigated whether the callus formation in the humerus during the distraction period of limb lengthening proceeds at a higher rate than that in the femur and tibia. Ten achondroplastic patients underwent 3 bilateral humerus, 3 bilateral femur and 4 bilateral tibia lengthenings. To reduce the confounding effect of bone size, we used bone mineral apparent density (BMAD) to compare the three groups; this is a volumetric bone mineral density measurement. BMAD in the distracted callus space was evaluated at 8 weeks after the start of distraction using dual-energy X-ray absorptiometry (mean +/- SD; g/cm3): in the humerus (0.24 +/- 0.08) it was significantly higher than in the tibia (0.10 +/- 0.02), while there was no difference between the humerus and femur (0.35 +/- 0.11). We conclude that the callus formation in the humerus during the distraction period of limb lengthening proceeded at a significantly faster rate than in the tibia, but there was no significant difference between the humerus and femur.

Achondroplasia↗
PubMed2004

Vertical alveolar bone distraction at molar region using lag screw principle.

PURPOSE: Recently, alveolar bone distraction has been widely used and several devices have been developed for this purpose. However, there are some disadvantages in each device, especially for distraction of posterior alveolar ridge. The purpose of this study was to develop a new device for vertical alveolar bone distraction at the molar region and to show the results of its clinical application. MATERIALS AND METHODS: The mechanism of device is based on lag screw principle and the device consists of the following 4 components; distraction screw, hole implant fixture, supporting plate, and temporary short implant and/or neighboring natural teeth. The distraction screw suspended at the supporting plate is inserted into the internal thread of the hole implant fixture placed at alveolar transport segment. If the distraction screw turns at the supporting plate, the hole implant fixture with transport segment moves to the supporting plate without vertical movement of the screw at the supporting plate like a lag screw. After an animal experiment using 4 beagle dogs, the device was clinically applied in 4 patients before implant insertion. RESULTS: The distraction of the alveolar bone could be successfully performed in all patients without any complications. The direction of distraction with this device could be adjustable, and the alveolar bone could be distracted not only vertically but also horizontally. Moreover, the surgical technique is simple with no need for a second surgery, and there is no occlusal disturbance from the device. CONCLUSIONS: The new device for alveolar bone distraction using lag screw principle can be used effectively in the molar region.

Adult↗
PubMed2006

[Digital lengthening by gradual distraction].

The authors report their experience of digital lengthening and analyze the indications and results of 12 cases performed over 13 years in the plastic and reconstructive surgery service of the Kassab institute. Distraction was performed using a mini-orthofix device. In majority of cases, the procedure was performed on young people, manual workers and victims of industrial accidents. The lengthened osseous segment was the 1st metacarpal in 7 cases, the proximal phalanx of the index in 3 cases, the 3rd metacarpal once and the proximal phalanx of the middle finger in one case. Gradual distraction at the rate of 0.25 to 0.5 mm/day was carried out in 10 cases using the procedure of "callotasis". In 2 cases the distraction was performed at a rate of 1 mm/day followed by bone graft. Callotasis allowed us to obtain an average lengthening of 17 mm (61.5%) in distraction of the phalanx, and 26 mm (63.3%) in distraction of the first metacarpal. This technique avoids the spontaneous shortening observed after the use of bone graft alone. Complications are relatively frequent but had little influence on the final result.

Adolescent↗
PubMed1998

Secondary lengthening of the reconstructed mandible using a gradual distraction technique--two case reports.

We have performed mandibular lengthening to restore oral function in 2 cases after tumour resection. Both cases had already undergone a vascularised fibular graft for mandibular reconstruction and had severe contracture and absence of an alveolar ridge for dentures. Gradual distraction was applied after corticotomy of the fibular bone at 0.9 mm per day. After completion of bone lengthening of 20-30 mm, both patients underwent a split thickness skin graft to obtain a good alveolar ridge for dentures and implants. Osteointegrated implants have since been applied in one of these cases, and the other patient has been able to eat a normal diet using dentures. Gradual distraction is applicable for vascularised bone grafts and useful for restoration of the alveolar ridge to accommodate dentures in cases with severe contracture of the oral space after tumour ablation.

Humans↗
PubMed2002

Changes in the protein expression of hedgehog and patched-1 in perisutural tissues induced by cranial distraction.

With the modern emphasis on minimally invasive therapies, the concept of distraction is being applied in the treatment of craniosynostosis. Although specific genetic mutations have been identified in craniosynostotic patients, changes in the gene expression induced by cranial distraction have not yet been explored. The effects of cranial distraction on hedgehog and patched-1 expression were evaluated in a rabbit model for craniosynostosis. Rabbits (n = 8) were divided into four groups: affected rabbits, wild-type rabbits, affected rabbits subject to cranial distraction, and wild-type rabbits subject to distraction. Perisutural tissue was examined using immunohistochemistry in four areas: suture, endosteum, periosteum, and osteocytes, for the expression of Indian hedgehog, sonic hedgehog, and desert hedgehog and their receptor, patched-1. Two experimental groups were compared: (1) wild-type before distraction to wild-type after distraction, and (2) synostotic before distraction to synostotic after distraction. Distraction produced several variable and interesting changes in hedgehog protein presence. In wild-type rabbits, the predominant effect was a mild decrease in Indian hedgehog levels. Sonic and desert hedgehog and patched-1 protein levels were unchanged. In synostotic rabbits, the predominant effect of distraction was to decrease Indian hedgehog, sonic hedgehog, and patched-1 protein levels. This was especially true in the periosteum and endosteum. Cranial distraction of normal and affected rabbits differentially changed both the expression levels and patterns of the hedgehog and patched-1 proteins in the cranial tissues examined. These results suggest that molecular and genetic parameters of distraction and bone response may be different in craniosynostotic individuals, which may influence treatment protocols in these patients.

Animals↗
PubMed2006

Long-term stability and growth following unilateral mandibular distraction in growing children with craniofacial microsomia.

BACKGROUND: The purpose of this study was to evaluate long-term mandibular skeletal stability and growth following unilateral mandibular distraction in growing children. METHODS: This retrospective longitudinal study of 12 consecutive patients with unilateral craniofacial microsomia who underwent mandibular distraction had a range of 5 years of postdistraction follow-up; five patients were followed for 10 years. Records included clinical photographs, dental study models, lateral and posteroanterior cephalograms, and panoramic radiographs obtained before distraction, at the time of device removal, and 1, 5, and 10 years after distraction. The mean patient age at the time of distraction was 48 months. The device was activated an average of 21.7 mm at the rate of 1 mm per day. The mean latency period was 6.1 days, and the mean consolidation period was 60.6 days. Fifty-two parameters were examined at each of the five time intervals. RESULTS: On average, the ramal length (condylion to gonion) increased 13.04 mm in the distracted rami. At 1 year after distraction, this dimension decreased by 3.46 mm. At 5 and 10 years after distraction, the average condylion-gonion dimension increased by 3.83 and 4 mm, respectively, with an average growth rate of 0.87 mm per year; during the same period, the unaffected ramus grew 1.15 mm per year. CONCLUSIONS: The distraction technique does not eliminate the inherent growth potential of the affected mandibular side. Facial asymmetry is significantly improved after distraction, and despite mild relapse observed during the first year, surgical correction is stable in the later years of follow-up.

Cephalometry↗
PubMed2000

Vertical distraction of the severely resorbed mandible. The Groningen distraction device.

In this paper, both the surgical procedure and the clinical results of a novel distraction device to augment a severely resorbed anterior edentulous mandible are described. The distraction device is non-voluminous, and consists of two distraction screws and one guide screw. Two months after the last day of distraction, both distraction screws are replaced by endosseous implants and the guide screw is removed. Three months after implantation, the prosthetic treatment can be started. So far three patients have been treated. In all patients, the severely resorbed mandible (mandibular height in the canine region: 5, 6 and 7 mm, respectively) could be sufficiently enlarged to enable reliable insertion of endosseous implants with a length of at least 12 mm. No complications occurred. Biopsies taken from the distraction site revealed formation of lamellar bone parallel to the distraction vector. From this preliminary study it is concluded that the Groningen vertical distraction device has the potential for reliable augmentation of the anterior segment of a severely resorbed edentulous mandible to enable insertion of endosseous implants with adequate length and primary stability.

Aged↗
PubMed2002

Clinical benefit of joint distraction in the treatment of severe osteoarthritis of the ankle: proof of concept in an open prospective study and in a randomized controlled study.

OBJECTIVE: Osteoarthritis (OA) is a degenerative, disabling joint disease that affects >10% of the adult population. No effective disease-modifying treatment is available. In the present study, we used joint distraction, a relatively new treatment in which mechanical contact between the articular surfaces is avoided while intraarticular intermittent fluid pressure is maintained, to treat patients with severe OA of the ankle. METHODS: Patients with severe ankle OA (n = 57) who were being considered for joint fusion (arthrodesis) were treated with joint distraction in an open prospective study. In addition, a randomized trial was performed in 17 patients to determine whether joint distraction had a better outcome than debridement. A standardized evaluation protocol (physical examination, assessment of pain, mobility, and functional ability) was used, and changes in radiographic joint space width and subchondral sclerosis were measured. Thirty-eight patients in the open study have been followed up for >1 year, with up to 5 years of followup in 7 of them (mean +/- SD followup 2.8 +/- 0.3 years). Patients in the randomized study have been followed up for 1 year. RESULTS: Significant clinical benefit was found in three-fourths of the 57 patients in the open prospective study. Most interestingly, the improvement increased over time. Radiographic evaluation showed increased joint space width and decreased subchondral sclerosis. Moreover, joint distraction showed significantly better results than debridement. CONCLUSION: The clinical benefit of joint distraction in the treatment of severe OA is proof of the concept. Although the followup remains relatively short and effects over time remain unpredictable, our study creates possibilities for the treatment of severe OA in general. Considering the high prevalence of OA and the lack of a cure for it, joint distraction as a treatment of severe OA may have great medical, social, and economic impact.

Adolescent↗
PubMed1998

Pre-surgical CT/FEA for craniofacial distraction: I. Methodology, development, and validation of the cranial finite element model.

Recently, surgeons have begun to treat serious congenital craniofacial deformities including craniosynostoses with mechanical devices that gradually distract the skull. As a prospective means of treatment planning for such complex deformities, FE models derived from routine preoperative CT scans (CT/FEA) would provide ideal patient specific engineering analyses. The purpose of this study was to assess the dimensional and predictive accuracy of the CT/FEA process through the development of a 3D model of a dry human calvarium subjected to two-point distraction ex vivo. Comparative skull measurements revealed that CT/FEA construction error did not exceed 1% for transcranial dimensions, and the thickness error did not exceed 8.66% or 0.31 mm. CT/FEA strain predictions for the central region of the skull, between the distraction posts, were not statistically different from homologous gage values at P < 0.05. Peripherally, however, the strain fields were less well behaved and the FE predictions showed only general qualitative agreement with gage recordings.

Biomechanical Phenomena↗
PubMed1999

Callus distraction of the midface in the severely atrophied maxilla--a case report.

OBJECTIVE: This report introduces the possibilities of callus distraction in the extremely atrophied, edentulous midface in a cleft lip and palate patient. INTERVENTION: After a subtotal Le Fort II osteotomy, tension wires were fixed to the zygomatic buttresses and frontal sinus walls by way of titanium miniplates and mesh and connected to a rigid external distractor. Then distraction of the whole midface (1 mm/d) was performed. RESULTS: Even in severe atrophy a distraction of the maxilla of 20 mm was possible. Stability has been shown for more than 5 months. CONCLUSIONS: Rigid external midfacial distraction may be used in difficult cases for the correction of sagittal discrepancies where conventional orthognathic surgery is likely to be insufficient. Further investigations will concentrate on the long-term outcome.

Adult↗
PubMed2006

Distraction vs remodeling surgery for craniosynostosis.

OBJECTS: We designed several distraction devices and applied these instruments in 14 patients with varying types of craniosynostosis. The aim of this report is to clarify the advantages and disadvantages of these surgical methods and to discuss current concepts for the surgical strategy in the treatment of craniosynostosis. METHODS: From January 2000 to July 2005, 28 patients with craniosynostosis were retrospectively analyzed. Surgical treatment was performed on 14 patients using the distraction method with internal distraction devices that we designed, in which 5 patients had plagiocephaly, 3 brachycephaly, and 6 scaphocephaly. All patients underwent preoperative and postoperative evaluations, which included the patient's neurological state, and three-dimensional CT. RESULTS: With distraction devices, the time required for the surgery could be shortened almost 3 1/3 h; the bleeding during the surgery was decreased with reduced requirement of more than 200 ml of blood transfusion as compared with remodeling surgery. Postoperatively achieved distraction distances varied from 30.0 to 47.5 mm (mean, 42.99 mm). The average increased volume percent of cranium in distraction surgery group was 20.9% (range, -11.5 to 58.9%) after full distraction. CONCLUSION: With distraction surgery, satisfactory cranial volume expansion and aesthetically pleasing morphological states were achieved in all cases, and the efficacy was statistically significantly high as compared with remodeling method.

Adolescent↗
PubMed1999

Distraction implants: a new operative technique for alveolar ridge augmentation.

In the past alveolar ridge augmentation was mainly based on autologous or allogenic bone transplants. Since 1996 alveolar ridge distraction has enabled local osseous build-up without bone transplantation. The 'distraction implant', uniting qualities of a distraction apparatus with those of a dental implant, has been in use for three years at the Department of Oral and Maxillofacial Surgery of Graz University. Its application in patients with alveolar ridge atrophy and other defects is demonstrated and the first results are presented in this study. Three patients with severe alveolar ridge atrophy of the edentulous mandible, three with extensive alveolar ridge defects and three with local alveolar defects following traumatic loss of a single tooth were treated with distraction implants. Segmental osteotomy was carried out in all patients and one or two distraction implants were positioned. Following this alveolar ridge distraction was carried out. In seven cases there were no complications, whereas in one patient distraction was discontinued, and altogether two distraction implants had to be removed. All complications were treated by conventional operative techniques. Fifteen of 17 distraction implants were loaded successfully. Alveolar ridge distraction by means of distraction implants is an adequate method of alveolar ridge augmentation resulting in improved implant sites and gingival conditions. The segment for distraction should not be smaller than an upper central incisor. The implants can be used for prosthetic treatment, but long-term results are still not finalised.

Adult↗