Craniofacial Distraction
Osteogenesis

INDIAN DENTAL ACADEMY
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Craniofacial Distraction
Osteogenesis

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Introduction




Distraction Osteogenesis is a biological process
of new bone formation between the surfaces of
osteomiz...
Origin and Evolution


Dentofacial Traction. Wescott first reported the
placement of mechanical forces on the bones of
th...




Goddard, in 1893 further standardized the
palatal expansion protocol, he activated the
appliance twice a day for 3 w...





In 1927, Abbot reported lengthening of tibia.
In 1927, Rosenthal reported first mandibular
osteodistraction proced...




In 1948, Crawford applied gradual incremental
traction to the fracture callus of the mandible.
In 1954, Ilizarov int...






The first report demonstrating the application of
Ilizarov principles to mandible appeared in 1973 by
Snyder et a...
Classification of Distraction Device
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External (Bone-Borne): Unidirectional,
Bidirectional and Multidirectional devic...
Biological basis of new bone formation


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Distraction osteogenesis begins with the
development of a reparative callus b...




Gradual incremental seperation of bone
segments places the callus under tensional stress
that aligns the newly forme...


1.
2.
3.
4.
5.

Clinically, distraction osteogenesis consists of
five sequential stages:
Osteotomy
Latency
Distraction
...
Osteotomy. Discontinuity of a skeletal segment
(also referred to as fracture) triggers an
evolutionary process of bone rep...
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

Latency. The latency is the period from bone
division to the onset of traction. Latency
represents the time allowed for...


During the following stage of soft callus that
lasts about 3 wks , capillaries continue to grow
into the fracture callu...




Distraction. During the normal fracture healing, the
stage of soft callus is followed by the stage of hard
callus, w...
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



During distraction, however, the normal process
of fracture healing is interrupted by the
application of gradual tra...




Ilizarov summarized the tension stress effect in
the folowing statement: “ Gradual traction of
living tissues create...




According to Ilizarov, the growth-stimulating
effect of tension activates the biologic elements
of the stretched sof...






As a result, the fibrous tissue of the soft callus
becomes longitudinally oriented in a direction
parallel to the...




After distraction ceases, bone trabeculae
continue to grow at the center of the regenerate
towards each other until ...
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



Remodeling The remodeling period is the period from
removal the distraction device to the application of the
full fu...




The cortical bone and marrow cavity are
restored. Haversian remodeling, representing the
last stage of cortical reco...
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Biomechanical Considerations


1)
2)
3)

The biomechanical parameters of
osteodistraction can be divided into several
cat...




Extrinsic parameters affect the mechanical
integrity of the distraction device, which in turn
influences the stabili...


Another critically important biomechanical
parameter of distraction osteogenesis is the
orientation of the distraction ...




Transverse Dimensions
Samchuko et al 1998(JOMFS) demonstrated that
bilateral lengthening of the mandibular corpus
wi...
www.indiandentalacademy.com




When the devices were placed parallel to the
direction, however, the lateral forces and the
tensile and compressive ...
www.indiandentalacademy.com


It follows that devices oriented parallel to the
body of the mandible may increase lateral forces
at the proximal segme...
www.indiandentalacademy.com




Incremental midline mandibular widening
demonstrated a gradual increase in intercondylar
angle because of transverse...




When the distractors were oriented parallel to
the direction of distraction (Model IV) the
intercondylar width was m...
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Sagittal Plane



The effects were demonstrated by Samchukov
1999.
A simulated osteotomy of the mandibular
corpus was pe...
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



Mandibular lengthening with the linear
distractors attached parallel to the inferior
border of the mandible increase...
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Soft tissue Adaptation
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Lengthening of the soft tissues is an important
part of the distraction process. Bone lengthe...
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1)

2)

Two predominant mechanisms of soft tissue
adaptation occur during distraction
histiogenesis:
Soft tissue regene...
Dental/PDL Distraction
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Orthodontic tooth movement is a process in
which a mechanical force is applied to induce
alveola...
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The process of osteogenesis in the periodontal
ligament during orthodontic tooth movement is
similar to that in the mid...
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The regular rate of osteogenesis in orthodontic
tooth movement during canine retraction is
about 1 mm per month, which ...
Technique of Dental distraction
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Liou and Huang 1998 AJODO
Right after the first premolar extraction, the
interseptal ...
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The depth of the undermining grooves is
dependent on the thickness of the interseptal
bone, as revealed on the peria...
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Liou and Huang (1998) reported that both the upper
and lower canines were distracted bodily 6.5 mm into
the extraction ...
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The radiographic examination revealed that
apical or lateral surface root resorption of the
canine was minimal. No peri...
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The radiographic changes of the periodontal
ligaments on the mesial side of the canines could
be classified into five s...
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Stage 1. Stretching and widening of the
periodontal ligament. This was in the first week
after initiating the distra...
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Stage 3. Recovery of the distracted periodontal
ligament. This occurred in the first to fourth
week after completing th...
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Stage 4. Remodeling of the striated bone occurs
from the fourth week to the third month after
completing the distractio...
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Stage 5. Maturation of the striated bone takes 3
months after completing the distraction. The
native lamina dura disapp...
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Why is the mesial movement of the first molar
minimal? After the initial tooth movement by a
light or heavy orthodon...
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The periodontal ligament is essentially a
hydrostatic system maintained by blood pressure
of the capillary bed. A force...
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Any technique that takes longer than 3 weeks to
retract a canine will result in loss of anchorage.
Because not only the...
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Why is the root resorption minimal? External
root resorption is initiated 2 to 3 weeks after the
orthodontic force is a...
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An association between the increased root
resorption and the duration of the applied force
has been reported. The durat...
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The best way to minimize the root resorption
induced by orthodontic tooth movement is to
complete the tooth movement in...
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Why can the canine be distracted so fast while
the first molar was still in the lag period? The
orthodontic tooth movem...
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After tooth extraction, regenerative bone tissue
will refill the extraction socket in 3 weeks and
become resistant and ...
Dentoalveolar Distraction
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First reported by Haluk Iseri and Reha Kisnisci
(JOMFS 2002)
A horizontal incision is made ...
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The holes are then connected with a straight
fissure bur. Fine vertical and horizontal
osteotomies are performed with c...
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Modified Dentoalveolar Distraction
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Yadav, Patil, Keluskar JIOS 2005
After making canine as a bone transport
segmen...
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Advantages of modification
Buccal cortical plate comes along with the
extracted premolar.
Time saving as cortic...
Distraction Protocol
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In periodontal distraction, canine is distracted
immediately after the surgical procedure 0.35
...
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In dentoalveolar distraction , canine is distracted
same day at a rate of 0.4mm per turn twice a
day.( Haluk Iseri e...
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In periodontal ligament distraction , the total
time required was 21 days where as in
dentoalveolar distraction a mean ...
Mandibular Alveolar Distraction Osteogenesis

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Maxillary Alveolar Distraction Osteogenesis

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Mandibular Distraction

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Maxillary Distraction with RED

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Surgically Assisted RME

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Soft tissue to hard tissue advancement ratios for
mandibular elongation using distraction osteogenesis
in children.
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Mel...
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The pre- and posttreatment lateral
cephalometric radiographs of 27 pediatric
patients who underwent bilateral mandibula...
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Horizontal advancement (in millimeters) of
bone and overlying soft tissue at these points
was collected from the radiog...
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A 1:0.90 mean ratio of bone to soft tissue
advancement was observed at B
point/labiomental sulcus and at pogonion/soft
...
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Magnitude of advancement, age, and sex of the
patient had no effect on these ratios in selected
population. This study ...
A meta-analysis of cleft maxillary osteotomy and
distraction osteogenesis.
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Cheung, Chua Int J Oral Maxillofac Surg. 200...
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In such cases it was feasible to use distraction to
correct moderate to large movement of the
maxilla by either complet...
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There is still no conclusive data on any
differences in surgical relapse, velopharyngeal
function and speech between th...
Sutural distraction osteogenesis (SDO) versus
osteotomy distraction osteogenesis (ODO) for
midfacial advancement


Liu et...
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When a Le Fort III osteotomy is needed, boneborne traction hooks are inserted through the
nostrils into a bone hole dri...
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All seven patients with midfacial hypoplasia
established a harmonious facial profile and
normal occlusal relationships....
Distraction osteogenesis and periodontal bone
regeneration
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Faber J Dent Res. 2005.

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The purpose of this study was to...
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Periodontal bone regeneration occurred in all
animals. Periodontal bone regeneration in the
distraction sites (Mean +/-...
Maxillary distraction osteogenesis to treat maxillary
hypoplasia: comparison of an internal and an
external system.

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K...
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At age 11 years 11 months, she received DO
with an internal device. The second patient, a
boy aged 11 years 7 months, w...
Single tooth dento-osseous osteotomy and distraction

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Kofod , Wurtz , Melsen AJODO 2005

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When teeth are replanted af...
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Ankylosed teeth can, however, serve as
anchorage for orthodontic correction of a
malocclusion and as a point of force a...


The tooth had become ankylosed, and it was
used to provide "free anchorage" during
distalization of the maxillary denti...
Indications
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Severe retrognathia associated with a syndrome
(eg, Pierre Robin syndrome, Treacher Collins
syndrome), e...
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Nonsyndromic mandibular hypoplasia
associated with a dental malocclusion (especially
if the advancement exceeds t...
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Mandibular hypoplasia due to trauma and/or
ankylosis of the temporomandibular joint.
Mandibular continuity defects...
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Distraction osteogenesis is showing great
promise in the treatment of OSA. Although
traditional combined maxillary and ...


This is likely because traditional mandibular
osteotomy has a physiologic limit of about 10
mm of advancement, which ma...
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Distraction osteogenesis allows for advancement
of up to 25 mm by using a specially designed
distraction device. In eff...
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Contraindications

No absolute contraindications to treatment exist.
However, relative contraindications are as
f...
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Adequate bone stock must be available to accept
the device and to provide adequate surface area
of the osteotomy ...
Conclusions
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In reality, traditional mandibular and maxillary
osteotomies will always have a role; however,
distraction ...
References
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Liou, Huang. Rapid canine retraction through distraction of
the periodontal ligament. Am J Orthod Dent...
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Graber, Vanarsdall. Orthodontics: Current
Principles & Techniques. 4th Edition. Elsevier
Mosby 2005
Proffit, Fiel...
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

Cope JB, Harper RP, Samchukov ML.
Experimental tooth movement through
regenerate alveolar bone: a pilot study. Am J
...




Tehranch, Behnia. Facial symmetry after
distraction osteogenesis and orthodontic therapy
Am J Orthod Dentofacial Ort...




Cope, Samchuko, Cherkashin. Mandibular
distraction osteogenesis: A historic perspective and future
directions Am J O...




Samchukov ML, Cope JB, Harper RP, Ross JD.
Biomechanical considerations for mandibular
lengthening and widening by g...




Yadav, Patil, Keluskar. Canine Distraction: A
review. JIOS 2005, 38; 212-217
Melugin , Hanson , Bergstrom , Schuckit...




Cheung,Chua. A meta-analysis of cleft maxillary
osteotomy and distraction osteogenesis. Int J Oral
Maxillofac Surg. ...




Faber, Azevedo, Bao. Distraction osteogenesis may
promote periodontal bone regeneration. J Dent Res.
2005 Aug;84(8):...


Kofod, Wurtz, Melsen. Treatment of an
ankylosed central incisor by single tooth
dento-osseous osteotomy and a simple
di...
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Distraction osteogenesis /certified fixed orthodontic courses by Indian dental academy

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Distraction osteogenesis /certified fixed orthodontic courses by Indian dental academy

  1. 1. Craniofacial Distraction Osteogenesis INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Craniofacial Distraction Osteogenesis www.indiandentalacademy.com
  3. 3. Introduction   Distraction Osteogenesis is a biological process of new bone formation between the surfaces of osteomized bone segments that are seperated gradually by incremental traction. According to Aranson ‘ Distraction Osteogenesis is mechanically induced, intramembranous ossification between two living bone surfaces acutely seperated by low energy techniques, undergoing gradual seperation. www.indiandentalacademy.com
  4. 4. Origin and Evolution  Dentofacial Traction. Wescott first reported the placement of mechanical forces on the bones of the maxilla in 1859. He used two double clasps seperated by a telescopic bar to correct a crossbite in a 15 yr old girl. A year later, Angell performed a similar procedure with a differentially threaded jackscrew connected to the premolars. www.indiandentalacademy.com
  5. 5.   Goddard, in 1893 further standardized the palatal expansion protocol, he activated the appliance twice a day for 3 wks followed by a stabilization period to allow the deposition of ‘Osseous material’ in the created gap. In 1905, Codvilla reported the first bone distraction for the treatment of shortened femur. www.indiandentalacademy.com
  6. 6.    In 1927, Abbot reported lengthening of tibia. In 1927, Rosenthal reported first mandibular osteodistraction procedure by using an intraoral tooth-borne appliance. In 1937, Kazanjian reported mandibular osteodistraction using a gradual incremental traction. www.indiandentalacademy.com
  7. 7.   In 1948, Crawford applied gradual incremental traction to the fracture callus of the mandible. In 1954, Ilizarov introduced his distraction osteogenesis technique for limb lengthening. The procedure was initiated by surgical bone division with maximum preservation of periosteum and endosteum- a technique that he called corticotomy. www.indiandentalacademy.com
  8. 8.    The first report demonstrating the application of Ilizarov principles to mandible appeared in 1973 by Snyder et al. In 1976, Michieli and Miotti demonstrated the feasibility of intraoral mandibular lengthening. In 1989, McCarthy et al were the first to apply the technique of Extraoral osteodistraction on 4 children with congenital craniofacial anomalies. www.indiandentalacademy.com
  9. 9. Classification of Distraction Device   External (Bone-Borne): Unidirectional, Bidirectional and Multidirectional devices. Internal (Subcutaneous or Intraoral): Intraoral Devices can be placed Extramucosal or Submucosal. These devices can be Bone-borne, tooth-borne or Hybrid. www.indiandentalacademy.com
  10. 10. Biological basis of new bone formation   Distraction osteogenesis begins with the development of a reparative callus between the surfaces of two bone segments surgically divided by a low energy osteotomy. After the callus has formed initially, a traction force is applied to these bone segments, which gradually pushes them apart. www.indiandentalacademy.com
  11. 11.   Gradual incremental seperation of bone segments places the callus under tensional stress that aligns the newly formed intersegmentary tissues parallel to the direction of traction. After the desired amount of lengthening is achieved, the distraction force is discontinued and the newly formed bone (distraction regenerate) undergoes maturation and remodeling until it becomes indistinguishable from the residual bone. www.indiandentalacademy.com
  12. 12.  1. 2. 3. 4. 5. Clinically, distraction osteogenesis consists of five sequential stages: Osteotomy Latency Distraction Consolidation Remodeling www.indiandentalacademy.com
  13. 13. Osteotomy. Discontinuity of a skeletal segment (also referred to as fracture) triggers an evolutionary process of bone repair similar to that observed during fracture healing.  Fracture healing has six sequential phases: 1) Impact 2) Induction 3) Inflammation 4)Soft callus 5) Hard callus 6) Remodeling  www.indiandentalacademy.com
  14. 14. www.indiandentalacademy.com
  15. 15.  Latency. The latency is the period from bone division to the onset of traction. Latency represents the time allowed for reparative callus formation. The stage of inflammation lasts from 1 to 3 days, at which time the bone segments are surrounded by granulation tissue consisting of inflammatory cells, fibroblasts, collagen and invading capillaries. www.indiandentalacademy.com
  16. 16.  During the following stage of soft callus that lasts about 3 wks , capillaries continue to grow into the fracture callus ; at this time the granulation and loose connective tissue are converted gradually to fibrous and cartilaginous tissue. www.indiandentalacademy.com
  17. 17.   Distraction. During the normal fracture healing, the stage of soft callus is followed by the stage of hard callus, which typically lasts 3 to 4 months. During this period , the fibrous and cartilaginous tissues of soft callus are transformed into woven bone by osteoblasts. This period is followed by the final stage of remodeling, when woven bone is remodeled slowly to lamellar bone with gradual reconstitution of the medullary canal. www.indiandentalacademy.com
  18. 18. www.indiandentalacademy.com
  19. 19. www.indiandentalacademy.com
  20. 20.   During distraction, however, the normal process of fracture healing is interrupted by the application of gradual traction to the bone segments at the stage of soft callus. This traction progressively seperates the bone segments, thereby generating tensional stress in the tissues of the forming soft callus and in the surrounding soft tissues. www.indiandentalacademy.com
  21. 21.   Ilizarov summarized the tension stress effect in the folowing statement: “ Gradual traction of living tissues creates stress that stimulates and maintains regeneration and active growth of these tissues”. In the forming soft callus tissues, tension stress creates a dynamic microenvironment and produces several specific changes that can be considered as a growth-stimulating effect and a shape-forming effect. www.indiandentalacademy.com
  22. 22.   According to Ilizarov, the growth-stimulating effect of tension activates the biologic elements of the stretched soft callus tissues resulting in increased proliferation of the fibroblastic cell population and prolongation of angiogenesis with tissue oxygenation. The shape-forming effect of tension alters the phenotypic expression of the ‘distraction’ fibroblasts, which appears as spindle shaped fibroblast like cells with hypertrophic intermediate filaments. www.indiandentalacademy.com
  23. 23.    As a result, the fibrous tissue of the soft callus becomes longitudinally oriented in a direction parallel to the axis of distraction. Consolidation The consolidation period is the period between cessation of traction forces and removal of the distraction device. This period represents the time required for complete mineralization of distraction regenerate. www.indiandentalacademy.com
  24. 24.   After distraction ceases, bone trabeculae continue to grow at the center of the regenerate towards each other until they overlap and fuse. The fibrous interzone gradually ossifies, and one distinct zone of woven bone completely bridges the gap, indicating a disappearance of soft callus stage. Although the distraction regenerate forms predominantly by intramembranous ossification, isolated islands of cartilage are often observed. www.indiandentalacademy.com
  25. 25. www.indiandentalacademy.com
  26. 26.   Remodeling The remodeling period is the period from removal the distraction device to the application of the full functional loading to the bone segment that contains the distraction regenerate. During this period, the zone of primary trabeculae in the center of the regenerate significantly decreases and later is resorbed completely. As the regenerate matures, the initially formed bony scaffold is reinforced by parallel fibrered and lamellar bone. www.indiandentalacademy.com
  27. 27.   The cortical bone and marrow cavity are restored. Haversian remodeling, representing the last stage of cortical reconstruction, normalizes the bone structure. Usually, the process takes a year before the structure of newly formed bony tissue is comparable to that of the preexisting bone. www.indiandentalacademy.com
  28. 28. www.indiandentalacademy.com
  29. 29. Biomechanical Considerations  1) 2) 3) The biomechanical parameters of osteodistraction can be divided into several categories: Extrinsic or fixator related factors Intrinsic or tissue related factors Factors related to device orientation www.indiandentalacademy.com
  30. 30.   Extrinsic parameters affect the mechanical integrity of the distraction device, which in turn influences the stability of bone fixation. Intrinsic parameters affect the quality of the forming distraction regenerate. www.indiandentalacademy.com
  31. 31.  Another critically important biomechanical parameter of distraction osteogenesis is the orientation of the distraction device and the resulting distraction vector relative to the anatomic axis of the bone segments, occlusal plane and desired direction of distraction. www.indiandentalacademy.com
  32. 32.   Transverse Dimensions Samchuko et al 1998(JOMFS) demonstrated that bilateral lengthening of the mandibular corpus with linear distractors attached parallel to the lateral surface of the mandible caused an increased intercondylar width during distraction. Because of limited lateral mobility of the condyles and rigid fixation of distraction devices to the body of the mandible, the tendency towards lateralization of proximal segments may generate unfavorable reactive forces. www.indiandentalacademy.com
  33. 33. www.indiandentalacademy.com
  34. 34.   When the devices were placed parallel to the direction, however, the lateral forces and the tensile and compressive strains were minimized significantly. Because device orientation causes an alteration in bony force level and strain patterns, it also has the potential to affect the quality and quantity of the regenerate tissue. www.indiandentalacademy.com
  35. 35. www.indiandentalacademy.com
  36. 36.  It follows that devices oriented parallel to the body of the mandible may increase lateral forces at the proximal segment and introduce compressive strains within the regenerate tissue, possibly inhibiting osteogenesis. www.indiandentalacademy.com
  37. 37. www.indiandentalacademy.com
  38. 38.   Incremental midline mandibular widening demonstrated a gradual increase in intercondylar angle because of transverse rotation of both condyles. When the distractors were oriented parallel to the mandibular body (Model III) the intercondylar width increased incrementally. www.indiandentalacademy.com
  39. 39.   When the distractors were oriented parallel to the direction of distraction (Model IV) the intercondylar width was maintained at all increments of lengthening. The condylar rotation seen during midline widening, if not compensated, can create inappropriate loading on the articular surface of the condyles, potentially causing degenerative changes. www.indiandentalacademy.com
  40. 40. www.indiandentalacademy.com
  41. 41. Sagittal Plane   The effects were demonstrated by Samchukov 1999. A simulated osteotomy of the mandibular corpus was performed posterior to the third molars bilaterally and linear distractors were oriented parallel to the inferior border of the mandible in Model V. In Model VI the distractors were oriented parallel to the occlusal plane. www.indiandentalacademy.com
  42. 42. www.indiandentalacademy.com
  43. 43.   Mandibular lengthening with the linear distractors attached parallel to the inferior border of the mandible increased the distance between maxillary and mandibular occlusal planes resulting in an increased lower anterior facial height. When the distractors were oriented parallel to the maxillary occlusal plane, no changes in LAFH occurred during the 10mm of mandibular lengthening. www.indiandentalacademy.com
  44. 44. www.indiandentalacademy.com
  45. 45. Soft tissue Adaptation   Lengthening of the soft tissues is an important part of the distraction process. Bone lengthening is possible because the bone is surgically divided into multiple segments where as soft tissues are stretched without any surgical procedure. Because of this, different biological mechanisms are involved in the soft tissue response to gradual stretching. This biologic process is termed ‘Distraction Histiogenesis’ www.indiandentalacademy.com
  46. 46.  1) 2) Two predominant mechanisms of soft tissue adaptation occur during distraction histiogenesis: Soft tissue regeneration following disruptive and degenerative changes Neohistiogenesis as a result of generalized cellular proliferation and growth. www.indiandentalacademy.com
  47. 47. Dental/PDL Distraction  Orthodontic tooth movement is a process in which a mechanical force is applied to induce alveolar bone resorption on the pressure side, and alveolar bone deposition on the tension side. On the tension side, the periodontal ligament is stretched (distracted) followed by alveolar bone deposition (osteogenesis). The periodontal ligament is a “suture” between alveolar bone and tooth. www.indiandentalacademy.com
  48. 48.  The process of osteogenesis in the periodontal ligament during orthodontic tooth movement is similar to that in the midpalatal suture during rapid palatal expansion, or to that in the midface sutures in the growing animal during midface distraction. The major difference is the rate of osteogenesis. www.indiandentalacademy.com
  49. 49.  The regular rate of osteogenesis in orthodontic tooth movement during canine retraction is about 1 mm per month, which is much slower than that in distraction osteogenesis. However, it has been shown that by orthodontically moving a tooth into the fibrous bone tissue just created by distraction osteogenesis in a canine model, the rate of the orthodontic tooth movement could be as much as 1.2 mm per week in the mandible. (Liou et al 1998) www.indiandentalacademy.com
  50. 50. Technique of Dental distraction   Liou and Huang 1998 AJODO Right after the first premolar extraction, the interseptal bone distal to the canine is undermined with a bone bur, grooving vertically inside the extraction socket, along the buccal and lingual sides, and extending obliquely toward the base of the interseptal bone to weaken its resistance. The interseptal bone is not cut through mesiodistally toward the canine. www.indiandentalacademy.com
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  52. 52.   The depth of the undermining grooves is dependent on the thickness of the interseptal bone, as revealed on the periapical films. A custom-made intraoral distraction device is delivered for canine distraction right after the first premolar extraction. It is activated 0.5 to 1 mm/day right after the extraction until the canine is distracted into the desired position and amount. www.indiandentalacademy.com
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  54. 54.  Liou and Huang (1998) reported that both the upper and lower canines were distracted bodily 6.5 mm into the extraction space within 3 weeks. New alveolar bone was generated and remodeled rapidly in the mesial periodontal ligament of the canine during and after the distraction. It became mature and indistinguishable from the native alveolar bone 3 months after distraction. During the distraction, 73% of the first molars did not move mesially and 27% of them moved less than 0.5 mm mesially within 3 weeks. www.indiandentalacademy.com
  55. 55.  The radiographic examination revealed that apical or lateral surface root resorption of the canine was minimal. No periodontal defect or endodontic lesion was observed throughout and after distraction. It was concluded that the periodontal ligament could be rapidly distracted without complications. www.indiandentalacademy.com
  56. 56.  The radiographic changes of the periodontal ligaments on the mesial side of the canines could be classified into five stages, from the initiation of the distraction to the complete remodeling of the new alveolar bone: www.indiandentalacademy.com
  57. 57.   Stage 1. Stretching and widening of the periodontal ligament. This was in the first week after initiating the distraction. Bone formation is not evident in this stage. Stage 2. Active growing of striated bone (new bone spicules) in the distracted periodontal ligament. This occurred during the second week after the initiation to the end of distraction. Striated bone was growing actively in the distracted periodontal ligament. www.indiandentalacademy.com
  58. 58.  Stage 3. Recovery of the distracted periodontal ligament. This occurred in the first to fourth week after completing the distraction. The striated bone became denser, gradually extending from the distal lamina dura (native lamina dura) of the interseptal bone, distal to the lateral incisor, toward the canine. The distracted periodontal ligament gradually decreased in width and back to normal. The radiographic characteristics of the striated bone created by the distraction were similar to a cortical bone or thickened lamina dura. www.indiandentalacademy.com
  59. 59.  Stage 4. Remodeling of the striated bone occurs from the fourth week to the third month after completing the distraction. The striated bone has gradually decreasing radiodensity, initiating from the native lamina dura toward the canine. It eventually would become the new lamina dura on the mesial side of the canine. The radiodensity of the remodeling striated bone is similar to the cancellous alveolar bone. The native lamina dura disappears gradually. www.indiandentalacademy.com
  60. 60.  Stage 5. Maturation of the striated bone takes 3 months after completing the distraction. The native lamina dura disappears and the new lamina dura is of normal thickness. On the radiographs, the interseptal bone between the lateral incisor and the canine is indistinguishable from the other interseptal bones. www.indiandentalacademy.com
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  62. 62.   Why is the mesial movement of the first molar minimal? After the initial tooth movement by a light or heavy orthodontic force, a lag period of minimal tooth movement persists for approximately 2 to 3 weeks before tooth movement again proceeds. The canine distraction is completed with the first molar still in its lag period or just initiating its mesial movement. www.indiandentalacademy.com
  63. 63.  The periodontal ligament is essentially a hydrostatic system maintained by blood pressure of the capillary bed. A force in excess of 26 g/cm2 was estimated to strangulate the periodontal tissues, forcing the tooth into physical contact with the alveolar bone and causing necrosis. The initial obstacle to orthodontic tooth movement is the necessary elimination of the necrotic (hyalinizing) tissues by undermining resorption. The elimination of the hyalinizing tissues takes 2 to 3 weeks, which is the lag period. www.indiandentalacademy.com
  64. 64.  Any technique that takes longer than 3 weeks to retract a canine will result in loss of anchorage. Because not only the canine but also the anchor unit will move to each other after the lag period. The average time of a canine retraction takes 4 to 6 months according to the anchorage needs. However, the anchor unit also will move forward accordingly (loss of anchorage). The best way to avoid losing anchorage is to move the canine before the anchor unit moves. www.indiandentalacademy.com
  65. 65.  Why is the root resorption minimal? External root resorption is initiated 2 to 3 weeks after the orthodontic force is applied and may continue for the duration of force application. In this technique, the canine distraction is completed within 3 weeks before the root resorption could initiate. www.indiandentalacademy.com
  66. 66.  An association between the increased root resorption and the duration of the applied force has been reported. The duration of the applied force is an aggravating factor for the root resorption, and it is regarded as a more critical factor than the magnitude of the force, especially in connection with long treatment periods. www.indiandentalacademy.com
  67. 67.  The best way to minimize the root resorption induced by orthodontic tooth movement is to complete the tooth movement in a short duration or even before initiation of root resorption. www.indiandentalacademy.com
  68. 68.  Why can the canine be distracted so fast while the first molar was still in the lag period? The orthodontic tooth movement is faster and root surface resorption is less in an alveolar bone with loose bone trabeculae and less bone resistance. In this technique, the canine is distracted into an extraction socket that has not been refilled by solid bone tissue. www.indiandentalacademy.com
  69. 69.  After tooth extraction, regenerative bone tissue will refill the extraction socket in 3 weeks and become resistant and solid in 3 months. If the canine is not retracted across the first premolar extraction socket in the first 3 weeks, the rate of tooth movement will slow down, root surface resorption will increase, and the anchor unit will start to move forward. www.indiandentalacademy.com
  70. 70. Dentoalveolar Distraction   First reported by Haluk Iseri and Reha Kisnisci (JOMFS 2002) A horizontal incision is made parallel to the gingival margin of the canine and the bicuspid beyond the depth of the vestibule. Flap elevation is done so that canine root is visualized properly. With a round carbide bur buccal cortical holes are made both mesial and distal to canine and are continued 2 to 3 mm beyond the apex of the canine. www.indiandentalacademy.com
  71. 71.  The holes are then connected with a straight fissure bur. Fine vertical and horizontal osteotomies are performed with curved and straight osteotomes to make canine a bone transport segment. The transport dentoalveolar segment includes the buccal cortex and the underlying spongy bone. The wound is thoroughly irrigated with saline and sutured. The device is fitted and cemented to canine and molar. www.indiandentalacademy.com
  72. 72. www.indiandentalacademy.com
  73. 73. Modified Dentoalveolar Distraction    Yadav, Patil, Keluskar JIOS 2005 After making canine as a bone transport segment, similar buccal cortical holes are made mesial and distal to first premolar and apically continued to the same depth as that of canine. The holes are connected with a straight fissure bur and premolar is extracted so the buccal cortical plate comes along with the extracted premolar. www.indiandentalacademy.com
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  75. 75.     Advantages of modification Buccal cortical plate comes along with the extracted premolar. Time saving as cortical plate need not be trimmed. Less chance of injuring the maxillary sinus lining. www.indiandentalacademy.com
  76. 76. Distraction Protocol   In periodontal distraction, canine is distracted immediately after the surgical procedure 0.35 mm turns twice daily. (Liou and Huang 1998 AJODO) In a recent study of periodontal distraction by Sayin etal (Angle Orthod 2005) canine was distracted immediately after the surgical procedure 0.25 mm per turn thrice a day.  www.indiandentalacademy.com
  77. 77.   In dentoalveolar distraction , canine is distracted same day at a rate of 0.4mm per turn twice a day.( Haluk Iseri et al (2002 JOMFS) In a recent study same authors mentioned that they start distraction within 3 rd day of the surgical procedure. (Iseri AJODO 2005) www.indiandentalacademy.com
  78. 78.  In periodontal ligament distraction , the total time required was 21 days where as in dentoalveolar distraction a mean of 10 days( 8 to 14 days). www.indiandentalacademy.com
  79. 79. Mandibular Alveolar Distraction Osteogenesis www.indiandentalacademy.com
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  85. 85. Maxillary Alveolar Distraction Osteogenesis www.indiandentalacademy.com
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  88. 88. Mandibular Distraction www.indiandentalacademy.com
  89. 89. Maxillary Distraction with RED www.indiandentalacademy.com
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  91. 91. Surgically Assisted RME www.indiandentalacademy.com
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  96. 96. Soft tissue to hard tissue advancement ratios for mandibular elongation using distraction osteogenesis in children.  Melugin Angle Orthod. 2006  Distraction osteogenesis is extensively used for the elongation of hypoplastic mandibles in children, yet the soft tissue profile response to this is not well understood. www.indiandentalacademy.com
  97. 97.  The pre- and posttreatment lateral cephalometric radiographs of 27 pediatric patients who underwent bilateral mandibular elongation using distraction osteogenesis were analyzed retrospectively to correlate horizontal soft tissue advancement with horizontal underlying bone advancement at B point and pogonion. www.indiandentalacademy.com
  98. 98.  Horizontal advancement (in millimeters) of bone and overlying soft tissue at these points was collected from the radiographs of each patient, and linear regression analysis was performed to determine the relationship of hard to soft tissue horizontal advancement at these points. www.indiandentalacademy.com
  99. 99.  A 1:0.90 mean ratio of bone to soft tissue advancement was observed at B point/labiomental sulcus and at pogonion/soft tissue pogonion. These ratios were consistent throughout the sample population and are highly predictive of the soft tissue response that can be anticipated. www.indiandentalacademy.com
  100. 100.  Magnitude of advancement, age, and sex of the patient had no effect on these ratios in selected population. This study assists with our understanding of the soft tissue response that accompanies bony elongation during distraction osteogenesis which will allow us to more effectively treatment plan the orthodontic and surgical intervention that will optimize the patients' functional and esthetic outcome. www.indiandentalacademy.com
  101. 101. A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis.  Cheung, Chua Int J Oral Maxillofac Surg. 2006  A PUBMED search of the National Library of Medicine from 1966 to December 2003 was conducted. Keywords used in the search were 'cleft', 'distraction', 'maxilla', 'maxillary', 'advancement', 'osteotomy', and 'orthognathic surgery'. This study concluded that distraction osteogenesis tends to be preferred to conventional osteotomy for younger CLP patients with more severe deformities. www.indiandentalacademy.com
  102. 102.  In such cases it was feasible to use distraction to correct moderate to large movement of the maxilla by either complete or incomplete Le Fort I osteotomy, and a concurrent mandibular osteotomy was less frequently required. Intraoperative and post-operative complications were uncommon with either technique, and some of the traditional ischemic complications related to conventional osteotomy were replaced by infection of the oral mucosa due to the prolonged retention of the distractors. www.indiandentalacademy.com
  103. 103.  There is still no conclusive data on any differences in surgical relapse, velopharyngeal function and speech between the two techniques. The authors concluded that both distraction osteogenesis and conventional osteotomy can deliver a marked improvement in facial aesthetics. www.indiandentalacademy.com
  104. 104. Sutural distraction osteogenesis (SDO) versus osteotomy distraction osteogenesis (ODO) for midfacial advancement  Liu et al J Craniofac Surg. 2005  The technique of osteotomy plus distraction osteogenesis is suitable for adult patients. The technique of sutural distraction osteogenesis is suitable for young patients, ages 6 through 12 years. The distraction system consists of a facebow, orthodontic elastics, and bone-borne traction hooks. The bone-borne traction hooks are made of titanium, with two traction hooks running laterally or downwardly. www.indiandentalacademy.com
  105. 105.  When a Le Fort III osteotomy is needed, boneborne traction hooks are inserted through the nostrils into a bone hole drilled at the lateralinferior pyriform aperture. When no osteotomy is needed, only the bone-borne traction hooks are placed. Heavy elastics were used in the technique of osteotomy distraction osteogenesis for Le Fort III osteotomy adult patients, whereas light forces and thus light elastics were used for younger patients. Three adult patients and four children were treated by osteotomy distraction and sutural distraction, respectively. www.indiandentalacademy.com
  106. 106.  All seven patients with midfacial hypoplasia established a harmonious facial profile and normal occlusal relationships. Radiographic examination showed balanced advancement of the midfacial skeleton. It is suggested that the treatment of midfacial hypoplasia in children by the technique of sutural distraction osteogenesis is to be preferred because of its simplicity and relative noninvasiveness. Thus, the authors suggest that midfacial hypoplasia should be treated at a younger age by this technique, potentially eliminating the need for a Le Fort III osteotomy at an older age. www.indiandentalacademy.com
  107. 107. Distraction osteogenesis and periodontal bone regeneration  Faber J Dent Res. 2005.  The purpose of this study was to test the hypothesis that periodontium can be consistently distracted toward the tooth crown to promote periodontal bone regeneration. After the surgical production of periodontal defects in maxillary canines of 5 mongrel dogs, periodontal bone distraction was performed. Light microscopy was used for histopathological and morphometric analysis. www.indiandentalacademy.com
  108. 108.  Periodontal bone regeneration occurred in all animals. Periodontal bone regeneration in the distraction sites (Mean +/- SD: 5.45 +/- 2.01 mm) differed from that in control sites (0.008 +/- 0.67 mm; p < 0.0001). Periodontal bone distraction resulted in periodontal bone regeneration. This finding may establish periodontal bone distraction as a new treatment alternative for periodontal defects. www.indiandentalacademy.com
  109. 109. Maxillary distraction osteogenesis to treat maxillary hypoplasia: comparison of an internal and an external system.   Kuroda et al AJODO. 2005 DO with a rigid external distraction (RED) system has been used for maxillary advancement; however, DO with internal devices is currently popular. This article described DO with an internal device and a RED system in 2 patients with maxillary hypoplasia with oligodontia. The first patient, a young girl, had a concave profile due to maxillary hypoplasia and 9 congenitally missing permanent teeth. www.indiandentalacademy.com
  110. 110.  At age 11 years 11 months, she received DO with an internal device. The second patient, a boy aged 11 years 7 months, was treated with DO with a RED system. In the girl, the maxilla was advanced 5.0 mm without any dentoalveolar compensation. In the boy, the maxilla was advanced 7.0 mm, but undesirable mesial movement of posterior teeth was observed. It was concluded that DO with internal devices is simpler and more useful than the RED system for maxillary hypoplasia with oligodontia. www.indiandentalacademy.com
  111. 111. Single tooth dento-osseous osteotomy and distraction  Kofod , Wurtz , Melsen AJODO 2005  When teeth are replanted after being avulsed, the repair process sometimes results in ankylosis. In a growing child, the ankylosed tooth fails to move along with the remaining alveolar process during vertical growth, resulting in a tooth that gradually appears more and more impacted and requires several reconstructive procedures to correct. www.indiandentalacademy.com
  112. 112.  Ankylosed teeth can, however, serve as anchorage for orthodontic correction of a malocclusion and as a point of force application for a dentoalveolar segment during alveolar distraction osteogenesis. A case report described the treatment of a 13-year-old girl whose maxillary left central incisor had been avulsed and replanted 5 years earlier. www.indiandentalacademy.com
  113. 113.  The tooth had become ankylosed, and it was used to provide "free anchorage" during distalization of the maxillary dentition. The underdeveloped alveolar process adjacent to the ankylosed tooth was reconstructed by dentoosseous segment distraction osteogenesis, by using the ankylosed tooth as the point of force application. www.indiandentalacademy.com
  114. 114. Indications   Severe retrognathia associated with a syndrome (eg, Pierre Robin syndrome, Treacher Collins syndrome), especially in infants and children who are not candidates for traditional osteotomies Unilateral hypoplasia of the mandible (eg, hemifacial microsomia) www.indiandentalacademy.com
  115. 115.    Nonsyndromic mandibular hypoplasia associated with a dental malocclusion (especially if the advancement exceeds the capabilities of a traditional osteotomy or if the patient is hesitant to undergo a bone graft harvest with the associated morbidity. Mandibular transverse deficiency associated with a dental malocclusion and dental crowding Severe OSA (respiratory disturbance index [RDI] >60) and in patients who are obese (body mass index [BMI] >28) www.indiandentalacademy.com
  116. 116.    Mandibular hypoplasia due to trauma and/or ankylosis of the temporomandibular joint. Mandibular continuity defects resulting from excision of tumors and/or aggressive developmental Shortened vertical height of the alveolar bone (Distraction of the alveolar segment can be performed to increase the vertical height in preparation for osteointegrated dental implant placement). www.indiandentalacademy.com
  117. 117.  Distraction osteogenesis is showing great promise in the treatment of OSA. Although traditional combined maxillary and mandibular osteotomy are effective in treating mild-tomoderate OSA, the results are disappointing in patients with severe OSA (RDI >60) and/or a high BMI (>28). www.indiandentalacademy.com
  118. 118.  This is likely because traditional mandibular osteotomy has a physiologic limit of about 10 mm of advancement, which may be insufficient to open the airway for effective relief of the obstruction in the obese patient or in those with severe disease. www.indiandentalacademy.com
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  121. 121.  Distraction osteogenesis allows for advancement of up to 25 mm by using a specially designed distraction device. In effect, the amount of distraction is individualized for each patient by performing polysomnography (PSG) after about 15-18 mm of advancement. If the PSG demonstrates a normal RDI, distraction is stopped to allow for consolidation. If the RDI is still elevated, distraction continues for the full 25 mm. www.indiandentalacademy.com
  122. 122.    Contraindications No absolute contraindications to treatment exist. However, relative contraindications are as follows: Patients who are unable or unwilling to comply with the distraction schedule are not ideal candidates for this procedure. Mandibular distraction osteogenesis has been performed on infants as young as 6 months, but more difficulty is encountered when dealing with small fragile bones in the placement of the distraction device. www.indiandentalacademy.com
  123. 123.    Adequate bone stock must be available to accept the device and to provide adequate surface area of the osteotomy sites for regeneration. Distraction osteogenesis of the mandible may be used on patients who have received prior radiation treatment. However, this procedure must be performed with caution because these patients are more likely to develop complications and to experience delays in wound healing. In older patients, the decreased number of mesenchymal stem cells may impair bone healing at the distraction site. www.indiandentalacademy.com
  124. 124. Conclusions  In reality, traditional mandibular and maxillary osteotomies will always have a role; however, distraction osteogenesis gives the surgeon another option in treating a wide variety of craniofacial deformities. www.indiandentalacademy.com
  125. 125. References    Liou, Huang. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofacial Orthop 1998;114:372-82 Cope, Samchukov. Regenerate Bone Formation and Remodeling During Mandibular Osteodistraction. Angle Orthod 2000;70:99–111. Cope JB, Samchukov ML, Cherkashin AM, Wolford LM, Franco P. Biomechanics of mandibular distractor orientation: An animalmodel analysis. J Oral Maxillofac Surg. 1999;57:952–964. www.indiandentalacademy.com
  126. 126.    Graber, Vanarsdall. Orthodontics: Current Principles & Techniques. 4th Edition. Elsevier Mosby 2005 Proffit, Fields. Contemporary Orthodontics. 3rd Edition. Mosby 2000 David M. Sarver. Esthetic Orthodontics & Orthognathic Surgery. Mosby 1998 www.indiandentalacademy.com
  127. 127.   Cope JB, Harper RP, Samchukov ML. Experimental tooth movement through regenerate alveolar bone: a pilot study. Am J Orthod Dentofacial Orthop. 1999;116:501–505. Bell WH, Harper RP, Gonzalez M, Cherkashin AM, Samchukov ML. Distraction osteogenesis to widen the mandible. Brit J Oral Maxillofac Surg. 1997;35:11–19. www.indiandentalacademy.com
  128. 128.   Tehranch, Behnia. Facial symmetry after distraction osteogenesis and orthodontic therapy Am J Orthod Dentofacial Orthop 2001;120:14953 Cope, Samchukov. Mineralisation dynamics of regenerate bone during mandibular osterodistraction. Int. J. Oral Maxillofac. Surg, 2001, 30:3 www.indiandentalacademy.com
  129. 129.   Cope, Samchuko, Cherkashin. Mandibular distraction osteogenesis: A historic perspective and future directions Am J Orthod Dentofacial Orthop 1999;115:448-60 Bell , Harper , Gonzalez , Cherkashin , Samchukov . Distraction osteogenesis to widen the mandible. Br J Oral Maxillofac Surg 1997;35:11-9. www.indiandentalacademy.com
  130. 130.   Samchukov ML, Cope JB, Harper RP, Ross JD. Biomechanical considerations for mandibular lengthening and widening by gradual distraction using a computer model. Am J Oral Maxillofacial Surg 1998;56:51-9. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices: a review of five cases. J Oral Maxillofac Surg 1996;54:45-53. www.indiandentalacademy.com
  131. 131.   Yadav, Patil, Keluskar. Canine Distraction: A review. JIOS 2005, 38; 212-217 Melugin , Hanson , Bergstrom , Schuckit, Bradley. Soft tissue to hard tissue advancement ratios for mandibular elongation using distraction osteogenesis in children Angle Orthod. 2006 Jan;76(1):72-6. www.indiandentalacademy.com
  132. 132.   Cheung,Chua. A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis. Int J Oral Maxillofac Surg. 2006 Jan;35(1):14-24. Liu, Hou, Liang, Huang, Zhang, Zhang H, Ma X, Song. Sutural distraction osteogenesis (SDO) versus osteotomy distraction osteogenesis (ODO) for midfacial advancement: a new technique and primary clinical report. J Craniofac Surg. 2005 Jul;16(4):537-48 www.indiandentalacademy.com
  133. 133.   Faber, Azevedo, Bao. Distraction osteogenesis may promote periodontal bone regeneration. J Dent Res. 2005 Aug;84(8):757-61. Kuroda, Araki, Oya, Mishima, Sugahara, TakanoYamamoto. Maxillary distraction osteogenesis to treat maxillary hypoplasia: comparison of an internal and an external system Am J Orthod Dentofacial Orthop. 2005 Apr;127(4):493-8. www.indiandentalacademy.com
  134. 134.  Kofod, Wurtz, Melsen. Treatment of an ankylosed central incisor by single tooth dento-osseous osteotomy and a simple distraction device. Am J Orthod Dentofacial Orthop. 2005 Jan;127(1):72-80 www.indiandentalacademy.com
  135. 135. Thank you For more details please visit www.indiandentalacademy.co m www.indiandentalacademy.com

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