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PubMed2005

Rigid external distraction using skeletal anchorage to cleft maxilla united with alveolar bone grafting.

OBJECTIVE: Documentation of the application of maxillary distraction osteogenesis using rigid external distraction (RED) with skeletal anchorage combined with predistraction alveolar bone grafting (ABG) in cleft maxilla. DESIGN: Case report. PATIENT: A patient with numerous congenital missing teeth and severe maxillary deficiency related to complete bilateral cleft lip and palate with large alveolar bone defect. INTERVENTION: The patient received preoperative orthodontic treatment, predistraction ABG, and maxillary distraction osteogenesis using RED with skeletal anchorage. RESULTS: Predistraction ABG completely united the cleft maxilla. The united maxilla was successfully advanced by the RED system with skeletal anchorage, despite unsound dentition with numerous congenital missing teeth. CONCLUSION: The present study demonstrates that the combination of predistraction ABG and RED system with skeletal anchorage is effective for the treatment of severe maxillary deficiency related to complete bilateral cleft lip and palate with large bone defect and numerous congenital missing teeth.

Adolescent↗

PubMed2001

Original sagittal split osteotomy revisited for mandibular distraction.

Introduction: A malformed mandible and an abnormally positioned mandibular foramen make it difficult to plan an ideal osteotomy line for mandibular distraction. In addition, there have been reports of such complications as nonunion, damage and stretch injury of the inferior alveolar nerve and tooth germ damage when conventional osteotomy or corticotomy are used for mandibular distraction. The authors utilized the original sagittal split ramus osteotomy for mandibular distraction. Patients and Methods: Five patients (three unilateral hemifacial microsomia, one bilateral hemifacial microsomia, and one mandibular retrusion) were included in this study of distraction osteogenesis using the sagittal split ramus osteotomy. Extraoral distraction devices were applied to the first four patients. An intraoral device with mono-cortical screw fixation was used for the fifth patient. Result: In all five cases, the results of the distraction were satisfactory. Complications (as listed) of conventional osteotomy when used for distraction were avoided. Satisfactory results were achieved and these were also well maintained postoperatively (mean follow up: 36 months). Conclusion: The authors believe that sagittal osteotomy for mandibular distraction osteogenesis makes it possible, to avoid injury to the inferior alveolar nerve during operation and stretching injury during distraction and to prevent tooth germ injury. It is also possible to diversify the osteotomy line for various force vectors to enlarge the bony contact surface area. Therefore, we suggest that sagittal split ramus osteotomy should be used as a preferred modification of osteotomy for mandibular distraction. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.

Journal Article↗

PubMed1998

Internal calvarial bone distraction in rabbits with delayed-onset coronal suture synostosis.

Recent studies have identified a subpopulation of craniosynostotic individuals who exhibit progressive or delayed-onset synostosis and mild craniofacial growth abnormalities. These individuals may be good candidates for nonextirpation, distraction osteogenesis therapy. The present study was designed to test this hypothesis by using internal calvarial bone distraction in a rabbit model with familial delayed-onset craniosynostosis. Data were collected from 159 rabbits: 71 normal controls, 72 with delayed-onset coronal suture synostosis, 8 with delayed-onset coronal suture synostosis and coronal suturectomy, and 8 with delayed-onset coronal suture synostosis and distraction. At 10 days of age, all rabbits had amalgam markers placed on both sides of the frontonasal, coronal, and anterior lambdoidal sutures. At 25 days of age, correction was accomplished through either a 5-mm-wide suturectomy or distraction osteogenesis. An internal distraction appliance was fixed to the frontal and parietal bones and percutaneously and intermittently activated at an average of 0.10 mm/day for 42 days (4.11 mm total). Serial radiographs were taken at 10, 25, 42, and 84 days of age. Results revealed that rabbits with delayed-onset synostosis had significantly (p < 0.01) reduced coronal suture growth rates (0.04 mm/day) compared with the other three groups (0.07 mm/day). Rabbits with suturectomy and rabbits with distraction showed similar coronal suture responses. However, from 42 to 84 days of age, rabbits with distraction showed reduced growth at the vault sutures and abnormal growth patterns in cranial vault width, cranial vault shape, and cranial base angulation compared with the other three groups. Results demonstrated that, although the normal coronal suture growth rate was maintained in rabbits with delayed-onset synostosis using intermittent distraction osteogenesis, normal adult craniofacial structure was not achieved. Such anomalous growth was probably a result of altered growth vectors and compressive forces at adjacent sutures during distraction. These findings suggest that distraction osteogenesis without corticotomy may be a treatment alternative in individuals with progressive, delayed-onset synostosis, but that internal appliances that generate low-level, continuous distractive forces should be investigated and developed.

Animals↗

PubMed2002

Use of ultrasound to assess healing of a mandibular distraction wound.

PURPOSE: A standardized, noninvasive technique to assess healing of the mandibular distraction wound is not available. Current methods include clinical examination, plain radiography, and computed tomography. These imaging techniques are expensive and obligate the patient to serial radiation exposure. In addition, anatomic overlap and metal artifacts may obscure the distraction gap. In contrast, ultrasound has been shown to be a noninvasive, efficient, and inexpensive way to evaluate bone healing. The purpose of this study was to test the feasibility of ultrasound to evaluate an experimental mandibular distraction osteogenesis wound. MATERIALS AND METHODS: Distraction devices were placed via a submandibular incision into 24 minipigs. The protocol consisted of 0-day latency and distraction rates of 1, 2, or 4 mm/d for a 12-mm gap. The wounds were assessed in vivo after 0, 8, 16, and 24 days of neutral fixation. Ex vivo radiographs were used to estimate bone fill using a semiquantitative score. A semiquantitative ultrasound score was assigned, and the beam penetration depth was measured in millimeters. RESULTS: In all groups, clinical stability of the distraction wound increased with the duration of fixation. Plain radiographs, taken during neutral fixation, showed that the desired distraction gap was achieved and maintained. The ultrasound score increased with fixation time, whereas beam penetration depth decreased as expected. Ex vivo radiographs showed increasing bone fill score with time and paralleled the ultrasound score. CONCLUSIONS: The results of this feasibility study indicate that ultrasound is potentially useful for the assessment of bone formation in distraction osteogenesis wounds.

Animals↗

PubMed2004

Swallowing disorders in Pierre Robin sequence: its correction by distraction.

Pierre Robin sequence is characterized by micro-gnathia, glossoptosis, feeding difficulties, and upper respiratory obstruction, which are frequently complicated by bronchial aspiration and pulmonary infection. Gastroesophageal reflux is also common in these patients. To assess the results of mandibular distraction, a study was performed in 18 patients to detect swallowing disorders associated with apnea episodes and gastroesophageal reflux. Polysomnography, barium pharyngoscopy, determination of blood gases, and esophageal pH measurements were undertaken before and 4 months after distraction osteogenesis. Bilateral corticotomies, followed by distraction with external devices, were performed, achieving 7 to 19 mm of elongation (mean = 12 mm). Gastroesophageal reflux was found in 83% of cases associated with apnea episodes, but it disappeared after distraction osteogenesis. Mean preoperative oxygen saturation was 72%, and it was 93% afterward. The preoperative apnea index was 18.3, and the preoperative 8.5 hypopnea index was 8.5; both disappeared. Pharyngeal transit time became less than 1 second after treatment. Abnormal tongue movements and barium stasis in the pharyngeal recess and in the trachea were eliminated in all the patients.

Deglutition Disorders↗

PubMed2000

[Mandibular hypoplasia. Growth induction by osteochondral transplants or callus distraction?].

In order to restore function and esthetics in mandibular hypoplasia, transplantation of osteochondral grafts and the distraction osteogenesis technique are used alternatively. In a retrospective study the indication, growth and complication rate of osteochondral graft and distraction osteogenesis cases in mandibular hypoplasia were compared. In total, 12 patients (4-14 years old; 7 female, 5 male) with different grades of mandibular hypoplasia received osteochondral grafts (7 costochondral, 5 iliac crest; observation period 4-9 years). In 5 patients (10-12 years old; 1 female, 4 male), distraction osteogenesis was performed (observation period 10 months to 3 1/2 years). In the results, according to the literature, the range of growth after osteochondral grafting varied considerably, approximate normal growth was noticed in only two cases. On the other hand, all patients treated by distraction osteogenesis showed a stable increase of bone length as expected. After osteochondral grafts, adequate growth is to be expected in the minority of cases and it does not seem predictable in individual cases. Therefore, the indication for osteochondral grafts should be restricted to severe hypoplasia, where the local amount of bone does not allow the use of a distraction device, and to cases where support of the mandibula at the skull base is necessary. In all other cases of mandibular hypoplasia in children, distraction osteogenesis should be discussed as the primary option, even if in the long term a second surgical procedure should be necessary.

Adolescent↗

PubMed2001

Deformation across the zone of callotasis during loading. radiostereometric analysis in a patient with achondroplasia.

The present study demonstrates that high-resolution radiostereometric analysis (RSA) can be used to assess global longitudinal compressive deformation across the callotasis zone during loading. In an achondroplastic patient operated with bifocal lengthening of the tibia by use of the Ilizarov external fixator, the axial compressive intersegmental strain in the proximal lengthening zone under a load of 71% of body weight was 7.7 mm. The proximal lengthening zone was 51.0 mm, and accordingly the overall linear strain across the callotasis was 15.1%. This large strain value found in distraction osteogenesis 6 weeks after end of distraction is not consistent with classical theory of the magnitude of micromotion needed for adequate stimulation of bone formation in fracture healing. The increased axial displacement did not stimulate bone healing and delayed union was observed. This one single observation does not allow for any conclusions to be drawn about the relationship of strain to fracture healing, but further and refined use of the RSA method will certainly improve our understanding of the role of axial strains in distraction osteogenesis.

Achondroplasia↗

PubMed2006

[Experimental study of mandibular periosteal distraction in rabbits].

OBJECTIVE: To investigate a novel technique for new bone formation--periosteal distraction osteogenesis. METHODS: A custom made periosteal distraction device was fixed to bilateral surface of the mandible in three rabbits. Periosteal distraction was performed on the left side of the mandible, the right side of the mandible served as the control. The animals were sacrificed at the end of distraction process. All the specimens were X-rayed and histologically examinated. RESULTS: All three animals survived with no obvious complications. Both in mass specimens and X-rays, there showed new bone formation on the distracted side of the mandible. In histological examinations, there was osteoblast-like cell infiltration and bone tissue formation in the distracted area. CONCLUSION: Periosteal distraction osteogenesis can provide a novel technique for the repair of bone defects.

Animals↗

PubMed2002

Mandibular distraction in neonates: a strategy to avoid tracheostomy.

Over the past 5 years, the authors developed an application of mandibular distraction osteogenesis to eliminate existing tracheostomy. That experience led the authors to attempt mandibular distraction osteogenesis in neonates as an alternative before tracheostomy. Success with this approach using supporting objective airway measurements has been reported previously. This report includes six neonates diagnosed with Pierre Robin sequence. Of the six, five neonates ranging in age from 6 to 26 days (mean, 14.5 days) were treated by the authors with mandibular distraction over a 22-month period. The sixth neonate was treated with tracheostomy, because of other airway abnormalities. Findings included retrognathia, glossoptosis, incomplete cleft palate, and airway obstruction in each patient. Birth weights ranged from 2.8 to 3.2 kg. All patients were unable to control their airway during feeding, as evidenced by repeated episodes of choking and obstruction. Resting oxygen saturations were in the 70 to 80 percent range in all patients, with further deterioration during attempted feeding. Bronchoscopy was performed in all patients under anesthesia before distraction. Recurrent near-complete and intermittent complete airway obstruction were present in all patients at the level of the tongue base. There was a consensus by a pediatric intensivist, a pediatric anesthesiologist, and a pediatric otolaryngologist in all cases. Each patient met all criteria requiring ventilation for life support. Tracheostomy would be required if mandibular distraction osteogenesis was not performed, or if it failed. Patients with other airway abnormalities were not considered for treatment. Maxillomandibular disharmony measured at the midline ranged from 8 to 15 mm (mean, 11.2 mm). Active distraction was performed at the rate of 1 to 2 mm a day, with a consolidation period of 4 weeks. Total time of treatment was less than 6 weeks in all cases. All patients were extubated by the completion of active distraction. Distraction distance ranged from 8 to 15 mm (mean, 12.4 mm). All patients were discharged to home on apnea monitors, the use of which was discontinued after 90 days with no further apneic events. Weight gains met or exceeded the average 500 g a month after distraction. Bronchoscopy at the time of distractor removal showed correction of airway obstruction at the tongue base. Radiographs showed bilateral ossification of the distraction sites. Tracheostomy was avoided in all cases selected for treatment by distraction. Patient follow-up range was 9 to 22 months. In selected Pierre Robin sequence patients with tongue base airway obstruction, mandibular distraction osteogenesis can successfully avoid the need for and the associated mortality and morbidity of indwelling tracheostomy.

Airway Obstruction↗

PubMed2003

Advances in distraction techniques for craniofacial surgery.

Distraction osteogenesis has been applied to the craniofacial skeleton as well as the long bones of the extremities. This technique does not require bone grafting and allows correction of craniofacial deformities with less invasion. Moreover, the distraction procedures can expand the overlying soft tissues simultaneously. We determined the indications of distraction osteogenesis, analyzed the types of devices available, and examined patients treated with distraction for the mandible, midface, and cranium. In all three sites, the devices tended to be the buried type and made of absorbable materials. Administration of some cytokines for shortening the consolidation period may be considered. Among disorders indicated for distraction osteogenesis, there are several syndromic craniosynostoses, which involve mutations in the fibroblast growth factor receptor (FGFR) 2 gene. The FGFR 2 mutation was suggested to clinically accelerate osteogenesis at the distraction site. The usefulness and appropriateness of the distraction protocol must be assessed for each individual disorder. Although distraction osteogenesis in the craniofacial skeleton has advanced technologically, all possible risks must be discussed with the patient and family members when obtaining preoperative informed consent, especially until establishment of fully safe distraction procedures.

Adult↗

PubMedDate not supplied

Zoledronic acid improves the mechanical properties of normal and healing bone.

OBJECTIVE: To determine the effects of the bisphosphonate zoledronic acid on the mechanical properties of normal and regenerating bone in a rabbit model of distraction osteogenesis. BACKGROUND: Bisphosphonate therapy is used for treating osteoporosis and, more recently, to enhance bone healing and reduce stress-shielding osteoporosis in distraction osteogenesis. METHODS: Thirty eight rabbits underwent 14 days of distraction osteogenesis on the right rear limb. They received either zero, one or two doses of intravenous zoledronic acid. Four point bending tests were performed to collect mechanical data. RESULTS: The peak load capacity of the regenerating bone was significantly increased by bisphosphonate therapy, but a similar trend in normal bone was not significant. The energy absorbed to failure did not vary significantly in either group. CONCLUSIONS: These data suggest that bisphosphonate therapy has a beneficial effect on the load capacity of regenerating bone, without increasing the brittleness of either new or existing bone. RELEVANCE: Zoledronic acid administration may be a potentially valuable adjunct to distraction osteogenesis treatment, to enhance bone strength, thus reducing refracture complications.

Animals↗

PubMed1995

Repeated mandibular lengthening in Treacher Collins syndrome: a case report.

A patient with mandibular hypoplasia associated with Treacher Collins syndrome was treated by bilateral distraction osteogenesis. Since less than optimal length was provided by the first distraction, a second corticotomy was performed in the newly formed bone 6 months after the first distraction. Thus bone gained by distraction osteogenesis was subjected to distraction once again. New bone formation occurred after the second lengthening. This case illustrated that distraction osteogenesis may be applied to the mandible at the site of previous distraction.

Bone Lengthening↗

PubMed2005

Apoptosis in the regenerate produced by mandibular osteodistraction in the mature rat.

UNLABELLED: AUTHORS: Liu ZJ, Anderson MW, Gu GM, King GJ. OBJECTIVE: Little is known about the contribution of apoptosis to the formation of the regenerate in distraction osteogenesis. This study investigated the role of apoptosis in the regulation of osteogenesis in relation to mandibular distraction rate and recovery time. METHODS: One hundred and twenty-nine 3-month rats received unilateral mandibular ramus osteotomy and distraction device placement. After 3-day latency, these were distracted for 5 days. The slow group was distracted a total of 1 mm (0.2 mm/day), the moderate 2 mm (0.4 mm/day), the rapid 3 mm (0.6 mm/day), and the sham was not distracted (0.0 mm/day). Eight to nine rats from each group were killed at 6 (mid-distraction), 10 (early-consolidation), 24 (mid-consolidation) and 38 (late-consolidation) days following device placement. Baseline data were obtained from an additional eight rats killed at day 3 (end of latency). Sagittal sections (7 mum) of the harvested hemi-mandibles were embedded in paraffin, double-stained with the DeadEnd(TM) Colorimetric TUNEL system for apoptotic cells and tartrate-resistant acid phosphatase for osteoclasts. Cell counts of apoptotic cells and osteoclasts (apoptotic or otherwise) were preformed at 40x magnification using a calibrated grid at the middle regions of the caudal, central and rostral parts of the distraction gap. Counting reproducibility was verified as <13%. RESULTS: Counts from all three regions were combined because no significant regional difference was found. The majority of the fibrous matrix regenerate was seen at days 6 and 10 while osseous regenerate occurred mainly at days 24 and 38. Significantly higher levels of apoptotic activity were seen at day 24. Apoptotic osteoclasts also peaked at day 24. Apoptotic cell numbers in the slow and moderate groups most closely followed the pattern of the sham in which the apoptosis activity peaked at days 10 or 24. However, those in the rapid group showed delayed peaks at days 24 or 38. CONCLUSIONS: Chalmers Street, Surry Hill, NSW 2010, Australia. gshe6437@mail.usyd.edu.au The transition from fibrous to osseous regenerate during mandibular distraction osteogenesis is accompanied by an increase in cell clearance via apoptosis. A slow to moderate distraction rate allows for the most typical pattern of bone healing while a rapid rate prolongs the healing process.

Animals↗

PubMed2001

Mandibular distraction force: laboratory data and clinical correlation.

PURPOSE: In vitro data were collected to measure torque-force values of an internal distraction device. The measurements were correlated with in vivo torque readings in an attempt to better understand the force required to distract the osteogenic bone callus of the human mandible during distraction osteogenesis. METHODS AND MATERIALS: Five internal craniofacial distraction devices were mounted on an apparatus to test load limits and torque measurements. The apparatus aligned the devices so that weight provided a force opposite and parallel to the vector of distraction. Weights were added in 5-lb increments, and the devices were activated 0.5 mm for each torque reading. Torque readings were obtained from a calibrated torque wrench. Measurements were plotted on a graph and correlated with clinical torque readings obtained from 8 patients undergoing mandibular lengthening. RESULTS: The average torque for distracting the human mandible 0.5 mm twice a day was 4.2 +/- 1.6 Newton-centimeters (N-cm). The average slope of the in vitro data shows that 4.2 N-cm of torque is equivalent to a force of 35.6 N. The average force of device failure was 235.8 N. CONCLUSION: Torque-force diagrams offer an effective means for calibrating safety margins and load capabilities for internal distraction devices. Quantification of axial forces encountered in mandibular lengthening will help contribute to the overall understanding and biomechanics of mandibular distraction osteogenesis.

Adolescent↗

PubMed2004

Distraction or osteotomy for the correction of maxillary cleft deformities: which is better?

The application of distraction osteogenesis in the maxillofacial region is gaining popularity. However, it remains controversial whether distraction osteogenesis can produce better outcomes than the conventional orthognathic surgery particularly in cleft lip and palate (CLP) patients. This paper presents the two treatment methods--conventional orthognathic surgery and distraction osteogenesis in the management of maxillary hypoplasia in CLP patients. One clinical case was selected for illustration on each method. The discussion is based on the current literature focusing on the differences in indications, surgical techniques, morbidities, relapse, speech and velopharyngeal changes.

Adolescent↗

PubMed2004

Mandibular distraction for micrognathia and severe upper airway obstruction.

OBJECTIVE: To determine whether the use of mandibular distraction osteogenesis (DOG) can help to avoid tracheotomy or achieve decannulation in patients with mandibular hypoplasia and severe upper airway obstruction. DESIGN: Retrospective medical record review (spanning a 27-month period). SETTING: Tertiary care children's hospital. SUBJECTS: Group A (n=8) was composed of infants with Pierre Robin sequence and no tracheotomy (mean age, 2.5 months); group B (n=6), older nontracheotomized micrognathic children with obstructive sleep apnea (OSA) (mean age, 69 months); and group C (n=12), tracheotomized children with complex congenital syndromes (mean age, 33 months). INTERVENTION: Bilateral mandibular DOG with endoscopic (n=24) and/or radiographic (n=17) airway evaluation (mean follow-up, 16 months [range, 2-42 months]). OUTCOME MEASURES: Group A, tracheotomy avoidance; group B, resolution of OSA (clinically or on polysomnography); and group C, decannulation. RESULTS: Group A, 7 patients (88%) successfully avoided tracheotomy; group B, 5 patients (83%) had resolution of OSA; and group C, 2 patients (17%) underwent decannulation. CONCLUSIONS: Mandibular DOG (1) allows tracheotomy avoidance in infants with isolated Pierre Robin sequence and (2) relieves OSA in older micrognathic children without tracheotomy. However, mandibular DOG does not frequently lead to decannulation in tracheotomized patients with complex congenital syndromes.

Case-Control Studies↗

PubMed2006

Optimum loading mode for axial stiffness testing in limb lengthening.

The axial stiffness of the regenerate is an indicator of bone healing after fracture or distraction osteogenesis. The axial stiffness may be assessed clinically by measuring the sharing of load between fixator and limb during loading. The aim of this study was to find out how to perform the stiffness test in order to minimize the influence of confounding factors to the test result. We investigated whether the test score was influenced by two factors: 1) the magnitude of the external load applied to the limb during the test; and 2) the patient's position during the test. The problem was approached by both a clinical study and by theoretical calculations. Thirty-three patients undergoing leg lengthening were tested regularly during the consolidation period. The stiffness test was executed with both high and low load, and in a standing and sitting position. There were significant differences in results between both the tests with high and low load, and between the standing and sitting tests. This indicated that both the magnitude of force and patient position during the test influenced the test result. Accordingly, these factors represent sources of error and must be taken into consideration when performing an axial stiffness test. The result of the theoretical calculations confirmed the result. We recommend performing the test while the patient is sitting, and to apply no more than 20% of the individual's body weight. It is also recommended that the same load be used in every test, when testing a patient several times during the treatment period.

Adolescent↗

PubMed2006

Forces involved in lower limb lengthening: an in vivo biomechanical study.

Despite improvements in surgical techniques for limb-lengthening procedures, the complication rate remains high. Bone fixators must cope with the forces involved during treatment, providing sufficient strength to maintain integrity of the limb in the course of lengthening, while permitting some "micromotion" across the bone gap that could enhance healing during the final phase of bone consolidation. This study reports on the forces generated during limb lengthening in the distraction and consolidation phases. Forces were measured on 19 patients between 6 and 22 years of age with 10 femoral and 11 tibial lengthenings of 1 mm/day by means of a monotube external fixator, fitted diaphysially, and modified to measure tension and weight-bearing forces. Peak force measured during the lengthening period amounted to about 14 N/kg of body mass. Generally, distraction forces leveled off at between 8 and 10 N/kg of body mass. During the consolidation period, the average force carried by the fixator dropped from 55% initially to about 10% of the force transmitted to the ground, consistent with increased load carrying capacity of the bone as healing progressed. Studying the forces involved in limb lengthening is important to gain knowledge of the forces required to overcome the resistance offered by the tissues that bridge the osteotomy site, to understand the biology of distraction osteogenesis and histiogenesis across the regenerate over time, and to provide scientific guidelines for frame removal.

Adolescent↗