Distraction osteogenesis (4)

“THE HIDDEN TRUTH”
(AN INSIGHT ON DISTRACTION)
www.indiandentalacademy.com

INTRODUCTION…
“FACE IS THE INDEX OF MIND”
It is true to the fact that every individual
wants to look beautiful .
With modern clinical techniques and
expertise, the awareness for treatment has
increased for both major and minor problems.
Cleft lip & palate is no exception.
With advent of “DISTRACTION
OSTEOGENESIS” 80% of the problem in CLCP can
be solved.

Historical Perspective
“Law of tension – stress” 1950,s by
GAVRIL ILLIZAROV
Principle of Placement of traction forces
on broken bones- 2000 years ago
HIPPOCRATES
First reported mechanical forces on
the Maxilla
WESCOTT 1859

First achieved RPE - ANGELL 1960
Standardized Palatal Expansion Protocol- GODDARD
1963
First Mandibular IntraOral Tooth Borne Osteodistraction
WASSMUND & ROSENTHAL 1972
New Design For Bone Fixation
GAVRIL ILLIZAROV 1951

Gradual Traction To Fracture Callus Of Mandible
CARWFORD 1984
Feasibility Of Mandibular Lengthening Using I O
Device
MICHIELI & MIOTTI 1976
First Mandibular Distraction In Humans
Mc CARTHY et al 1989
Modified ‘L’ shaped Mandibular Osteodistraction
KAZANJIAN 1973

First To Apply Alveolar Mandibular Distraction
CHIN & TOTH 1996
First To Use Bi-directional Mandibular Distractor
MOLLINA et al 1997
First to Developed Tooth Borne Hybrid RED
RAZADOLSKY et al 1998
First Bone Borne Titanium Device
MANRIC 1999

WHAT IS DISTRACTION.?
“DISTRACTION OSTIOGENESIS”
It is a technique by which bone
generation and osteosyntesis is achieved
by distracting a native pre existing bone
by gradual mechanical traction of both
segments,which initiates a sequence of
adaptive changes termed
“DISTRACTION HISTOGENESIS”www.indiandentalacademy.com

Distraction Osteogenesis begins with
the development of reparative
callus ,which consists of three
sequential periods,
 Period of Latency
 Period of Distraction
 Period of Consolidation

INFLAMATION
SOFT CALLUS
LATENCY PERIOD
From the time of bone division to the onset of
traction (i.e.) time allowed for callus
formation.
The following Histological Sequence take place :

DISTRACTION PERIOD
 The normal process of fracture healing is
interrupted by gradual mechanical traction.
 During distraction, morphogenesis take
place
 Care should be taken to maintain
1. The Rate
2. The Rhythm
3. The Direction (Vector of force)

CONSOLIDATION PERIOD
 The fibrous inner zone ossifies and
a distinct zone of woven
bone completely bridges the
gap.
 The new bone regenerated is
oriented along the path of
distraction vector.

The bone thus formed shows increased
density adjacent to the residual
bone and a radiolucent central zone.
 Onset of Histogenesis takes place.

Following the surgical separation
By 3 weeks
Lasts 3-4 Months
Fibrous Bone + Type II Collagen
INFLAMATION
T
R
A
C
T
I
O
N
SOFT CALLUS
HARD CALLUS
REMODELLING

Indications
Maxillary hypoplasia in cleft lip &
palate patients.
Obstructive sleep apnoea syndrome.
Treacher Collins syndrome .
SARPE.
Maxillary Canine retractions.
Expansion of Mandibular symphysis …
etc.

WHAT IS DISTRACTION
ORTHODONTICS.?
 Pre Distraction Orthodontics
 Orthodontics During Distraction
 Post Distraction Orthodontics

Pre Distraction
Orthodontics
Removal of dental compensation
Preliminary alignment
Coordination of the arches

Orthodontics During
Distraction
 Check for the orientation of the
device
 Check for the vectors
 Check for any neuromuscular
influence

Post Distraction Orthodontics
Correction of cant of occlusal
plane, if any.
Correction of occlusion.

To assess the stress distribution & forces
around the the cleft Maxilla using two
types of Sagittal distraction technique with
F.E.M.
 To assess the clinical out come of two types
of sagittal distractors fixed to R.E.D.
 To correlate the FEM out come with the
clinical cases.
Aim Of The Study

Study Protocol
The study was conducted in Two Parts.
 10 Cleft patients between the age
group of 20-25 yrs.
All the patients with soft tissue primary
closure of lip /palate were selected.

 The patients were divided into 2
groups of 5 each.
 In Group –I “MINI PLATES” were
fixed to the maxilla which in turn was
fixed to RED.
 In Group –II “TOOTH BORNE SPLINT”
were fixed to the maxilla which in
turn was fixed to RED.

 3 D C.T scan of the patients were
taken.
 F.E.M modeling was done & the
force mimicking distraction were
applied.
 The pattern of stress distribution in
and around the maxilla were
observed.
 The F.E.M pictures of stress &
force distribution were correlated
clinically.
PART ONE OF THE STUDY

3D C T of a Cleft Patient Used For
Modeling

Finite Element Modeling
C.T Scan
Modeling
Meshing
Boundary
Loading
Ezidicon & e film
Autocad (04 version) &
Proengineer (01version)
ANSYS(Version 8)

FEM Pictures Of MAXILLA &
MINIPLATE
Meshing with boundary
conditions
Meshing with miniplates
Maxilla mimicking cleftwww.indiandentalacademy.com

FEM Pictures Of MINIPLATE With
Distraction Force Applied
Stress distribution around the
miniplates
Stress distribution around the
maxilla
Stress distribution around the posterior
segment of maxilla

FEM of Stress Distribution with
Miniplate

FEM Pictures Of MAXILLA & TOOTH
BORNE SPLINT Force Location
Meshing with
boundary conditions
Maxilla mimicking cleft
Meshing with tooth
borne splint

FEM Pictures Of TOOTH BORNE
SPLINT With Distraction Force
Maximum stress distribution
around the dentoalveolar segment
Maximum
stress
around
the PDL

FEM Of Stress Distribution with
Tooth borne Splint

 Pre Distraction Orthodontics was done
 On Group-I Patient “Mini Plates” were
fixed on the Maxilla which in turn was
fixed to the R.E.D
 On Group-II Patient “TOOTH BORNE
SPLINT” was cemented to the
Maxillary dentition which in turn was
fixed to the R.E.D
 Le forte-I cuts were made and
distraction initiated .
Part Two of the study

Distraction Protocol
 After the le fort cuts are made and
R.E.D fixed, a latency period of 1week
was given.
 Usually the latency period for older
individuals are more when compared
with younger ones.

In the Distraction Period ,Activation
of 1mm/day(0.5mm twice a day)
was done till the desired distance of
distraction was achieved
A Consolidation period of around 8
weeks was given, Which is usually
3 to 4 times the activation period

Usually 10% more of the desired distance
is done to counter the relapse.
According to literature the relapse
tendency in distraction is 5% to 7%
when compared to cleft maxillary
osteotomy which is 15% to 20%.
 In our study the patient were put on
“REVERSE PULL HEAD GEAR” after the
consolidation period to hold the
maxilla after distraction.

Clinical Cases
CASE REPORT 1
 20 year / F
 Diagnosis
Complete CLCP
Primary closure of the palate/Lip.
※ Collapsed maxilla sagitally
/transversally
 Treatment protocol
Predistraction orthodontics
Distraction with miniplates fixed to
RED
Post distraction orthodontics.www.indiandentalacademy.com

Pre Treatment Intraoral Photographs

Intraoral Photograph After
Expansion & Immediate Strap-Up

Intraoral Photograph After Aligning

Lefort I cut

Mini plates in place

Distractor in place

Rigid Extraoral
Distractor
Patient with the
Distractor

Intraoral Photographs After
Distraction & Settling

Extraoral Photographs After
Distraction

Pre Distraction
Post Distraction
Extra Oral Photograph
Comparison

Preoperative IntraOral Postoperative IntraOral
Intra Oral Photograph
Comparison

Pre-Distraction
Distraction
Post-Distractionwww.indiandentalacademy.com

Cephalometric Superimposition Of
Pre & Post Distraction
Post
Pre

CASE REPORT 2
 24/F
 Diagnosis
Complete CLCP
Absence of premaxilla
With primary closure of the Lip
Collapsed maxilla sagitally
 Treatment protocol
Predistraction orthodontics
Distraction with tooth borne splint fixed to
RED
Post distraction orthodontics
FPD for 12,11,21,22.
Rhinoplasty.
Clinical
Cases

Pretreatment IntraOral Photographs

Immediate Strap Up

Fabrication Of Tooth Borne Splint

Tooth Borne Splint Tried Intraorally
Before Distraction

Tooth borne splint in place

Patient With The Distractor

IntraOral Photograph After
Distraction With Face Bow

IntraOral photograph after
Distraction & Settling

Preoperative Intra Oral Postoperative Intra Oral
Intra Oral Photograph Comparison

Pre Distraction Post Distraction
Extra Oral Photograph
Comparison

Pre-Distraction
Distraction
Post-Distraction
LATERAL CEPHALOGRAM COMPARISON

Results Of The Study
Part-I FEM Study,
 The distraction with MINI PLATES
were more effective than TOOTH
BORNE SPLINT in the ‘Z’ & ‘X’
direction.
 Stress distribution was less around
the tooth & PDL with Miniplates
when compared with Tooth Bornewww.indiandentalacademy.com

Results Of the Study
Part –II Clinical study (Mini Plates),
The patients with Miniplates &
Distractor showed faster recovery.
Orthodontics could be started
immediately after the consolidation
period.
The upper arch could be corrected
independently while distraction.www.indiandentalacademy.com

Results Of the Study
Part –II Clinical Study (Tooth Borne
Splint),
The patients with tooth borne splint
showed slightly slower recovery.
The brackets has to be removed to fix
the splint & hence no further
orthodontics could be done in the upper
arch while distraction.www.indiandentalacademy.com

Some more time has to be given than
the consolidation period for the PDL to
recover .
The over all time for the orthodontic
treatment to complete increased.
Results Of the Study…..
Part –II Clinical Study (Tooth Borne Splint),

Future Directions
 Refinements in distraction protocol.
 More sampling is necessary.
 Accurate modeling (Stereolithography).
 Modifications in osteotomy cuts.
 Newer technique to monitor distraction.
 Refinements in RED to make it more acceptable.
 “Motorized Distractors”.
 “Nano Distractor”.

CONCLUSION
The technique of maxillary distraction
osteogenesis using RED especially with “MINI
PLATES” may be a better alternative for
maxillary hypoplasia in CLCP patient.
In all cases favorable skeletal, dental & soft
tissue profiles have been successfully achieved.
This is definitely a “Emerging Challenge“ and a
“Newer Solution” to treat CLCP patients.

Don’t judge each day by the harvest you
reap, but by the seeds you plant
…..Robert Louis
Stevenson

Distraction osteogenesis (4)

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