Distraction osteogenesis


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Distraction osteogenesis

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
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  3. 3. Events in Distraction Osteogenesis -Initiation with incremental traction to the reparative callus -Tension within the callus stimulates new bone formation parallel to the vector of distraction. www.indiandentalacademy.com
  4. 4. •Tension is created in the surrounding soft tissues leading to Distraction Histogenesis(active histogenesis in skin, fascia,blood vessels , nerves , muscle , ligament,cartilage & periosteum.) www.indiandentalacademy.com
  5. 5. It was introduced by Ilizarov in 1951. It is a unique form of tissue engineering Using easily controlled mechanical condition that is slow gradual distraction of the corticotomized www.indiandentalacademy.com
  6. 6. Or osteotomized bone fragment A clinician is able to guide the formation of new bone and its spatial orientation to form a structural part of distracted bone. www.indiandentalacademy.com
  7. 7. This happens without application of any growth factor or other controlling agent. Distraction can be done of various cranio-facial structures like Mandible,mid-facial ,zygomas , cranium related to dental field www.indiandentalacademy.com
  8. 8. DEFINITION “It is the regeneration of bone between vascularized bone surface that are separated by gradual distraction” www.indiandentalacademy.com
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  10. 10. DENTOFACIAL TRACTION - As early as 1728, fauchard used expansion arches - Ideally shaped metal plates ligated to the crowded dentition - Wescott in 1859 reported - mechanical force on maxilla www.indiandentalacademy.com
  11. 11. - He used double clasp seperated By a telescopic bar to correct a Cross-bite - Angel in 1859 first achieved rapid palatal expansion - Goddard in 1893,further standardized the palatal expansion www.indiandentalacademy.com
  12. 12. INITIAL PHASE OF DISTRACTION -In 1905 Codvilla performed first bone distraction-femur -In 1927,Abbott applied same concept for tibia www.indiandentalacademy.com
  13. 13. -Wassmund,rosenthal in1927 performed first osteodistraction www.indiandentalacademy.com
  14. 14. In 1937, Kazanjian also performed mandibular osteodistraction by using gradual incremental traction instead of acute advancement .After performing modified Lshaped osteotomies in the corpus, he attached a wire hook to the symphysis, thereby providing direct skeletal fixation to the bone segment to be distracted. www.indiandentalacademy.com
  15. 15. With the introduction of D.O.G craniofacial surgery entered the latest phase It is ironical that Ilizarov spend his professional carrier in developing the technique on the long bones www.indiandentalacademy.com
  16. 16. The craniofacial skeleton are much more suited for distraction - membranous in embryological origin - smaller in dimension - richer blood supply He utilized a primitive external ring fixator to compress the injured bone ends www.indiandentalacademy.com
  17. 17. By chance ,a patient reversed the compression rod, thereby distracting the bone fragment Ilizarov observed new bone formation radiologically and pursued this new method experimentally and clinically www.indiandentalacademy.com
  18. 18. All early studies were done in long bones like Tibia,femoral, ulnar,radius e.t.c Distraction of craniofacial skeletal by synder et al in 1973 at 1mm/day for 14 days www.indiandentalacademy.com
  19. 19. Next applied by michieli and miotti in italy to increase mandibular length by 15mm at the rate of 0.5mm/day followed by 40 days of fixation In 1990 Karp et al at new york performed a unilateral angular osteotomy in the canine mandible. www.indiandentalacademy.com
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  21. 21.  Bone is a dynamic organ that can regenerate.  Regeneration may be defined “as restoration of form and function indistinguishable from that derived embryological ”.  Developmental insufficiency , pathology ,surgical resection and avulsion can lead to osseous defects. www.indiandentalacademy.com
  22. 22.  Regenerative capacity of bone help in correcting these deficits.  Various biological factors as hormones,prostaglandin, cytokines and growth factor www.indiandentalacademy.com
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  25. 25.  Bone fracture repair requires remodeling of cortical and cancellous components Cortical bone remodeling includes (B.M.U) synchronized team of osteoblast and osteoclast www.indiandentalacademy.com
  26. 26.  Osteoclast-cutting cone of BMU burrow through cortical plate. Originates from circulating mononuclear precursor.  Osteoblast-produces over abundance bone the callus.And there,after excess callus is again removed by osteoclast www.indiandentalacademy.com
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  28. 28. Critical factors of the process appears to be 1. Stability of fixation 2. Rate of daily distraction 3. Preservation of local soft tissue envelope 4. Vascular supply www.indiandentalacademy.com
  29. 29.  Pure lengthening procedure  Corrective distraction osteotomies  Transportation distraction  Stimulation of growth within growth plate in growing children www.indiandentalacademy.com
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  33. 33. -Vector depends on orientation of distraction device to skeletal anatomy -Devices are oriented to occlusal plane -In case of significant irregularity occlusal plane long axis of body of mandible is used www.indiandentalacademy.com
  34. 34.  VERTICAL  HORIZONTAL  OBLIQUE www.indiandentalacademy.com
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  36. 36.  The pin-bone interface is most critical factor for the performance of external fixation  Loosening of external fixation pins www.indiandentalacademy.com
  37. 37.  Pin tract problem can be controlled, but established regimens must be followed during insertion and post operative care Most important factor single factor causing pin loosening is unstable fixation www.indiandentalacademy.com
  38. 38. A.Orthofix ,B.Hoffmann ,C.Ace D.Apex blunt ,E.Apex sharp www.indiandentalacademy.com
  39. 39. INDICATION FOR D.O Craniofacial microsomia uni-bilateral Nager’s syndrome Treacher collins syndrome Pierre robin syndrome TMJ ankylosis www.indiandentalacademy.com
  40. 40. Post traumatic disturbance Developmental microsomia Midfacial hypoplasia (craniofacial synostosis syndrome) Condylar regeneration Expansion of mandibular symphis (brodie syndrome) www.indiandentalacademy.com
  41. 41. CHARACTERSTICS OF DISTRACTION DEVICE Type of device Extra oral Intra oral www.indiandentalacademy.com
  42. 42. - Initially all experimental works in membranous bone lengthening was performed on mandible - The protocol for correction depends on degree and type of deformity www.indiandentalacademy.com
  43. 43. -Treatment choice depends purely on individual patient need -In 1990 Karp et al performed a unilateral angular osteotomy in canine mandible -After 10 days of external fixation mandible was distracted at 1mm/day for 20 days and held in fixation for 56 days www.indiandentalacademy.com
  44. 44. DISTRACTION ON DOGS www.indiandentalacademy.com
  45. 45. DEVELOPMENT OF BONY REGENERATION www.indiandentalacademy.com
  46. 46. PRE OPERATIVE CLINICAL EXAMINATION • Extra oral and intra oral examination should be done with extra care • Check for asymmetries and deformities in detail • Function of TMJ before distraction • Mouth opening. www.indiandentalacademy.com
  47. 47. DIAGNOSTIC RECORDS PHOTOGRAP H www.indiandentalacademy.com
  48. 48. RADIOGRAPHIC P-A VIEW www.indiandentalacademy.com
  49. 49. •Placement of head in cephalostat is altered in unilateral craniofacial microsomia. •The ear is placed down and forward in affected side. •The technician should make clinical evaluation of a line perpendicular to the Mid sagittal plane www.indiandentalacademy.com
  50. 50. 3-DIMENSIONAL CEPHALOGRAM www.indiandentalacademy.com
  51. 51. 3-D CT SCANNING www.indiandentalacademy.com
  52. 52. OCCLUSAL CANT www.indiandentalacademy.com
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  54. 54. DEPENDING ON PLANE EXTRA-ORAL APLIANCES UNI-PLANAR www.indiandentalacademy.com
  55. 55. A. External uni planar distraction appliance In 1992,mcCarthy et al introduced this appliance to successfully lengthen the mandible unilaterally in 3 children and bilaterally in 1 child Approx. 20-24mm of bone stock posterior to last tooth bud is necessary to place this device. www.indiandentalacademy.com
  56. 56. Ortiz-monasterio and molina modified illizarov technique by performing incomplete corticotomy.  They left internal cortical plate and cancellus layer intact and used semi rigid distractor. www.indiandentalacademy.com
  57. 57. B. External bi-planar distractor www.indiandentalacademy.com
  58. 58.  Bi planar distractor provides an additional plane of correction  More severe mandibular hypoplasia, such as Nager’s syndrome involves deficiency in more than one plane  Following a single or double osteotomy, one can distract both vertically and horizontally www.indiandentalacademy.com
  59. 59.  In very difficult cases of mandibular hypoplasia, a double osteotomy may be undertaken in order to obtain two callus sites. This allows a more rapid distraction as well as the development of a mandibular angle. Klein and Howaldt introduced a device capable of achieving controlled changes in angulation. www.indiandentalacademy.com
  60. 60. C. External multi planar distractor www.indiandentalacademy.com
  61. 61.  Multi planar devices has capability to do correction in all three planes. The hypo plastic mandible not only deficient in ramus height and body but effected ramus may lie in more medial position, resulting in decreased bigonial distance. www.indiandentalacademy.com
  62. 62. SURGICAL PROCEDURE  Buccal surface of hypoplastic ramus is approached via either an intra-oral or extra-oral  Initial cases were done through an extra-oral incision but as clinical experience increased intra-oral approach was used www.indiandentalacademy.com
  63. 63.  In either incision area is anesthetized  In intraoral approach incision is made over the external oblique line and buccal surface is exposed in sub periosteal plane.  Raise a full-thickness flap, separating the muscle from the overlying periosteum. Identify the area of bone deficiency. Identify and mark the area of preplanned mandibular osteotomy. www.indiandentalacademy.com
  64. 64.  In transcutaneous approach, a 3-cm incision is made in the skin lines of the submandibular fold at a position along the angle and inferior border of mandible www.indiandentalacademy.com
  65. 65. - Selection of pin-hole site requires careful attention - As drill hole determines position of device and vector of distraction. - One must be sure that pin projects sufficiently above the skin - After the pin holes are drilled saline irregation should be done to prevent bone necrosis www.indiandentalacademy.com
  66. 66.  Then 50mm half pins are inserted  In intra oral approach a trocar is used to permit percutaneous drilling of holes as well as insertion of half pins. www.indiandentalacademy.com
  67. 67.  It is technically best to perform or complete osteotomy after distraction appliance is tightened.  A mechanical saw supplemented by saline irrigation can be used  The osteotomy is is completed by inserting and rotating An osteotome by Separating bone Segment. www.indiandentalacademy.com
  68. 68.  Irrigate the wound and close it with 4-0 cat gut suture. www.indiandentalacademy.com
  69. 69. TO MOVE A RAIDER  Loosen the fixation screw ("F") by turning the screw turn counter-clockwise using the provided screwdriver.  Using the screwdriver, turn the advancement screw ("M") to move the rider in the desired direction. The distance the rider is moved is indicated by the scale (marked in 1mm increments) etched on the geared rod. www.indiandentalacademy.com
  70. 70. Once the desired position of the rider is reached, the rider must be stabilized by tightening the fixation screw ("F"). This is done by turning the screw clockwise. Because the distraction process will be carried out primarily by home-caregivers (relatives or friends of the patient), the fixation and advancement screws are clearly marked with the letters "F" and "M", respectively. www.indiandentalacademy.com
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  72. 72. • In 1987, Guerrero applied the first intraoral tooth-borne appliance for osteodistraction of the mandibular symphysis. • In 1990 , he reported the results of intraoral mandibular widening on eleven patients with transverse deficiencies ranging from 4 to 7 mm.He used the same principles that Bell and Epker described for palatal expansion of the maxilla . www.indiandentalacademy.com
  73. 73. • After a vertical symphyseal osteotomy, a custom made Hyrax appliance was placed and initially activated 48 hours after surgery. Depending upon the resistance of the soft tissues, 2 to 4 activations were applied per day to achieve the desired expansion www.indiandentalacademy.com
  74. 74. • In 1994, McCarthy and co-workers developed a miniaturized bone-borne Uniguide™ Mandibular Distraction Device suitable for intraoral placement .Similar to his extraoral appliance, the device consisted of two clamps that were attached to the bone via pairs of pins connected by a telescopic distraction rod. www.indiandentalacademy.com
  75. 75. • At the same time, Wangerin in Germany designed a similar appliance – the Intraoral Titanium Mandibular Distraction Device . The device consists of two mini plates for bone fixation connected by a square-shaped distraction cylinder. www.indiandentalacademy.com
  76. 76. WIDENING OF SYMPHYSIS www.indiandentalacademy.com
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  80. 80. RAMUS OSTEOTOMY DISTRACTION www.indiandentalacademy.com
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  83. 83. INTRAORAL MAXILLO-MALAR DISTRACTION TECHNIQUES •Maxillary malar deficiency is a common deformity. •U shaped palatal osteotomy performed •A-P distractor placed after completion of malar maxillary osteotomy www.indiandentalacademy.com
  84. 84. -Osteotomy includes malar bone. -Extends posteriorly pterygomaxillary suture , posterior aspect of zygoma.Same cuts are made on opposite side. www.indiandentalacademy.com
  85. 85. -Then malarmaxillary complex is displaced using curved osteotome behind maxillary tuberosities www.indiandentalacademy.com
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  87. 87. Maxillary Distraction Procedure Maxillary Distraction procedures deliver traction forces through the dentition to the maxillary bone. To apply traction through the dentition a rigid intraoral splint is required. www.indiandentalacademy.com
  88. 88. The Intraoral Splint: • Orthodontic bands with 0.050inch headgear tubes are fitted either on first permanent molars or second primary molars(below 6yrs). The splint is made with 0.045/0.050 SS rigid wire. •Two straight pieces of 0.050 SS wire are soldered perpendicular to the labial wire. www.indiandentalacademy.com
  89. 89. • The long ends of these wires are bent anterior to the lips in a circle to have a rigid eyelet to apply traction. • To control the direction of traction forces relative to the approximate center of resistance of the maxilla and also to avoid irritation to the lip. www.indiandentalacademy.com
  90. 90. The RED Device : After completion of the osteotomy, the halo portion of the RED device is adjusted and rigidly fixed around the head with scalp screws. A vertical bar was connected to the halo and a horizontal bar with the distraction screws. www.indiandentalacademy.com
  91. 91. -The traction hook and traction screws were connected with a 25guage surgical wire. -Latency period :4 to 6 days after osteotomy. -Active distraction :1 to 1.5mm per day -Rigid retention :without active distraction for 2 to 3 weeks -final retention : elastic retention with face mask for 4 to 6 weeks two 6-oz elastics www.indiandentalacademy.com
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  93. 93.  The orthodontist has an extremely important role to play right from diagnosis and treatment planning till the end of the treatment  1. 2. 3. It is divided into 3 stages Pre distraction orthodontics During distraction orthodontics Post distraction orthodontics. www.indiandentalacademy.com
  94. 94. Pre distraction orthodontics A. Removal of dental compensation- teeth should be moved to ideal position relative to the basal bone so that ideal maxilomandibular relationship is not compromised. B. Preliminary alignment- crowding,rotation, extruded and intruded teeth should be corrected before distraction procedure is initiated www.indiandentalacademy.com
  95. 95. C. Coordination of archwidth-patients with severe mandibular retrognathism will have transverse maxillary deficiency also. It is appropriate to expand maxilla before distraction. D. Surgical hooks-passive rigid rectangular full size wires are placed with surgical hooks for use of intermaxillary guiding elastics during active stage of distraction www.indiandentalacademy.com
  96. 96. During distraction orthodontics A. Orientation of device-depending upon type of deficiency, orientation should be done based on occlusal plane to obtain predictable changes (bilateral or unilateral) B. Distraction device can be uni-directional, bi-directional, multi-directional C. Application of external influence-this is applied by clinician by activating the device to achieve desired results www.indiandentalacademy.com
  97. 97. Post distraction orthodontics -After consolidation and removal of appliance orthodontist has to give final finishing of occlusion -In cases of unilateral distraction patient has canted occlusal plane which can be corrected by selective tooth eruption www.indiandentalacademy.com
  98. 98. - Unilateral distraction patients have tendency of laterognathism causing posterior cross-bite which can be corrected by combination of TPA, lingual arch, cross elastics,palatal expansion appliance www.indiandentalacademy.com
  99. 99. Alveolar Distraction • Alveolar deformities and defects may result from a variety of pathological processes including 1) developmental anomalies, such as cleft palate and congenital tooth absence, 2) maxillofacial trauma, which often involves damage to the teeth and associated jaw structures, and 3) periodontal disease leading to bone and tooth loss from the alveolar process. www.indiandentalacademy.com
  100. 100. These deformities may be managed by a variety of surgical techniques , such as autogenous onlay bone grafting, alloplastic augmentation, connective tissue grafting, guided tissue regeneration or non-surgical techniques such as facilitation of supraeruption in periodontally compromised alveolar ridges. www.indiandentalacademy.com
  101. 101. Distraction Of The Periodontal Ligament(Dental Distraction) • To achieve rapid canine retraction in 3 weeks, the first premolar was extracted and the interseptal bone distal to the canine was undermined, grooving vertically inside the socket with a bone bur AJO/1998/ERIC LIOU AND C.SHING www.indiandentalacademy.com
  102. 102. Then, an intraoral distraction device was placed to distract the canine distally, with an activation of 0.5 to 1.0 mm/day. The anchor units were, second premolar and first molar. The canines were bodily distracted 6.5 mm into the extraction space in 3 weeks . Anchor loss was nil in 73% and 0.5 mm in 27% of the cases. www.indiandentalacademy.com
  103. 103. Future Of Distraction Osteogenesis • Development of osteotomy techniques that allow division of bone without disruption of periosteum, endosteum,neurovascular bundle & blood supply. • Motorized distraction units with remote activation & monitoring for precise dimensional control and calibration of distraction forces. www.indiandentalacademy.com
  104. 104. • Use of bioresorbable materials such as Lactosorb(a copolymer of poly-l-lactic acid-82% & poly glycolic acid-18% ). IMPLANT PLATES www.indiandentalacademy.com SCREWS
  105. 105. Distraction Osteogenesis has taken many different forms and has evolved into its own super-speciality of orthognathic treatment for various congenital and post-traumatic incidences of mandibular and maxillary fracture and deformity. As an Orthodontist we should know that how to proceed in various stages of distraction to achieve the best results. www.indiandentalacademy.com
  106. 106. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com