Distraction osteogenesis

DISTRACTION OSTEOGENESIS – ADISTRACTION OSTEOGENESIS – A
FAREWELL TO MAJOR OSTEOTOMIES ?FAREWELL TO MAJOR OSTEOTOMIES ?
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The treatment of craniofacial deformitiesThe treatment of craniofacial deformities
poses a great challenge to theposes a great challenge to the
Orthodontist and the Oral Surgeon alike.Orthodontist and the Oral Surgeon alike.

Treatment modalitiesTreatment modalities
•Functional appliances in the growingFunctional appliances in the growing
years.years.
•Orthognathic Surgery.Orthognathic Surgery.

The latest technique for combating theThe latest technique for combating the
same is a procedure termedsame is a procedure termed
“DISTRACTION OSTEOGENESIS”“DISTRACTION OSTEOGENESIS”

SCOPE OF THE TALKSCOPE OF THE TALK
• A look at the origins of DOA look at the origins of DO
• DO in the long bonesDO in the long bones
• DO in the craniofacial regionDO in the craniofacial region

SCOPE OF THE TALKSCOPE OF THE TALK
• Biologic effects of DOBiologic effects of DO
• Factors affecting DOFactors affecting DO
• The role of an Orthodontist in DOThe role of an Orthodontist in DO

DISTRACTION OSTEOGENESISDISTRACTION OSTEOGENESIS
(Transosseous synthesis)(Transosseous synthesis)
(Osteodistraction)(Osteodistraction)
DEFINITION: A process of new boneDEFINITION: A process of new bone
formation between the surfaces of boneformation between the surfaces of bone
segments gradually seperated bysegments gradually seperated by
incremental traction -incremental traction - COPECOPE (1999)(1999)

Steps involved :Steps involved :
a)a) Corticotomy/OsteotomyCorticotomy/Osteotomy
b)b) Latency periodLatency period
c)c) Distraction phaseDistraction phase
d)d) Consolidation phaseConsolidation phase
RateRate
RhythmRhythm

a)a) Corticotomy/OsteotomyCorticotomy/Osteotomy : A low energy: A low energy
osteotomy of the cortex preserving theosteotomy of the cortex preserving the
local blood supply to both the cortex andlocal blood supply to both the cortex and
the medullary canal.the medullary canal.

b)b) Latency periodLatency period : The time following the: The time following the
osteotomy when initial fracture healingosteotomy when initial fracture healing
bridges the cut bone prior to initiating thebridges the cut bone prior to initiating the
distraction.distraction.

c)c) Distraction phaseDistraction phase ::
i) Rate – the number of millimeters/day ati) Rate – the number of millimeters/day at
which the bone surfaces are stretched.which the bone surfaces are stretched.
ii) Rhythm – The number of incrementalii) Rhythm – The number of incremental
distractions per day.distractions per day.

d)d) Consolidation phaseConsolidation phase : The time following: The time following
distraction, for which the device is stabilized.distraction, for which the device is stabilized.

DISTRACTION HISTOGENESISDISTRACTION HISTOGENESIS
The sequence of adaptive changes in the softThe sequence of adaptive changes in the soft
tissues, adjacent to the distracted segments.tissues, adjacent to the distracted segments.
Healing IndexHealing Index: The number of days or months: The number of days or months
from the surgery to full, unprotected loadfrom the surgery to full, unprotected load
bearing for each centimeter of bone length.bearing for each centimeter of bone length.

HISTORICAL PERSPECTIVEHISTORICAL PERSPECTIVE
• ALESSANDRO CODIVILLA – 1905ALESSANDRO CODIVILLA – 1905
• LEROY ABBOT – 1927LEROY ABBOT – 1927

ALESSANDRO CODIVILLA – 1905ALESSANDRO CODIVILLA – 1905

LEROY ABBOT – 1927LEROY ABBOT – 1927

KAZANJIAN -- 1937KAZANJIAN -- 1937

Problems with the earlier attempts:Problems with the earlier attempts:
a)a) Lack of control of the bone segmentsLack of control of the bone segments
b)b) Inadequacy of the appliancesInadequacy of the appliances
c)c) Instability of fixation and complicationsInstability of fixation and complications

GAVRIIL ILIZAROV (1951) rejuvenated theGAVRIIL ILIZAROV (1951) rejuvenated the
procedure when he accidentally found thatprocedure when he accidentally found that
new bone growth was possible.new bone growth was possible.

Theories favouring Compression in Bone healing:Theories favouring Compression in Bone healing:
i.i. Roux’s hypothesisRoux’s hypothesis
ii.ii. Wolff’ doctrineWolff’ doctrine
iii.iii. Huter-Volkmann theoryHuter-Volkmann theory

ILIZAROV’S TECHNIQUEILIZAROV’S TECHNIQUE
Foundations laid via rigorous experimentationFoundations laid via rigorous experimentation
a)a) Dog experimentsDog experiments (Long bones)– 7 groups(Long bones)– 7 groups
• Group I,II and III differed in the type of fixationGroup I,II and III differed in the type of fixation
• Group IV and V in the amount of marrowGroup IV and V in the amount of marrow
• Group VI and VII underwent transverseGroup VI and VII underwent transverse
distractiondistraction

Foundations laid via rigorous experimentationFoundations laid via rigorous experimentation
b)b) Dog experimentsDog experiments (Membrane bones)(Membrane bones)
Distraction results were similar to that seen in theDistraction results were similar to that seen in the
long bones.long bones.

Membrane bone experimentMembrane bone experiment

• Limb lengthening proceduresLimb lengthening procedures
• Correction of angular deformitiesCorrection of angular deformities
• Repair of fracture, mal-unionRepair of fracture, mal-union
• MiscellaneousMiscellaneous

ILIZAROV’S EXTERNAL RING FIXATORILIZAROV’S EXTERNAL RING FIXATOR

ILIZAROV’S CRITERIAILIZAROV’S CRITERIA
a)a) Surgical procedure must involve minimumSurgical procedure must involve minimum
marrow; hence, corticotomy preferred.marrow; hence, corticotomy preferred.
b)b) Fixity of the device: Rigid fixation is a must.Fixity of the device: Rigid fixation is a must.
c)c) Rate: Optimal to be 1 mm per dayRate: Optimal to be 1 mm per day
d)d) Rhythm: Optimum of 2-4 activations/dayRhythm: Optimum of 2-4 activations/day

THE TENSION-STRESS EFFECTTHE TENSION-STRESS EFFECT
The histologic evidences of Ilizarov’s work formThe histologic evidences of Ilizarov’s work form
the basis of distraction procedures in any partthe basis of distraction procedures in any part
of the body.of the body.
These histologic findings were coined by IlizarovThese histologic findings were coined by Ilizarov
as the ‘Tension-Stress’ effect.as the ‘Tension-Stress’ effect.

THE TENSION-STRESS EFFECTTHE TENSION-STRESS EFFECT
FZ- Fibrous Inter-zoneFZ- Fibrous Inter-zone
MZ- Mineralising ZoneMZ- Mineralising Zone

SNYDER (1972,73) resected a dog mandible andSNYDER (1972,73) resected a dog mandible and
performed distraction successfully.performed distraction successfully.
10 week healing period followed by distraction10 week healing period followed by distraction
of 1mm/day for 14 days.of 1mm/day for 14 days.
MICHELLI and MIOTI (1977) and PANIKAROVSKIMICHELLI and MIOTI (1977) and PANIKAROVSKI
(1982)carried out modified experiments in the(1982)carried out modified experiments in the
canine mandiblescanine mandibles

Mc’Carthy– (1989) conducted the first reportedMc’Carthy– (1989) conducted the first reported
human trial of craniofacial distraction usinghuman trial of craniofacial distraction using
external fixators.external fixators.

4 children with craniofacial anomalies were4 children with craniofacial anomalies were
subjected to a distraction protocol of uptosubjected to a distraction protocol of upto
three weeks followed by a 8-10 weekthree weeks followed by a 8-10 week
consolidation.consolidation.
Long-term studies of the same patients indicate aLong-term studies of the same patients indicate a
successful result.successful result.

MOLINA and ORTIZ MONASTERIO(1995) used bi-MOLINA and ORTIZ MONASTERIO(1995) used bi-
directional appliancesdirectional appliances
Mc’CARTHY demonstrated the efficacy of aMc’CARTHY demonstrated the efficacy of a
mulitdirectional appliance.mulitdirectional appliance.
GUERRERO (1990) used an intra-oral appliance toGUERRERO (1990) used an intra-oral appliance to
widen mandibular arches.widen mandibular arches.

Evolution of distraction appliancesEvolution of distraction appliances

GUERRERO –Intra-oral devicesGUERRERO –Intra-oral devices

Midface distraction –Midface distraction – RACHMIEL (1993) carriedRACHMIEL (1993) carried
out midface distraction on sheepout midface distraction on sheep

A BIRD’S EYE-VIEW THE ORIGINS ANDA BIRD’S EYE-VIEW THE ORIGINS AND
EVOLUTION OF DO IN THE CRANIOFACIALEVOLUTION OF DO IN THE CRANIOFACIAL
REGIONREGION
a)a) Phase of traction without surgeryPhase of traction without surgery
b)b) Upsurge in limb-lengthening proceduresUpsurge in limb-lengthening procedures
c) Progression from Extra-oral Unidirectional toc) Progression from Extra-oral Unidirectional to
Extra-oral Multidirectional distraction.Extra-oral Multidirectional distraction.

A BIRD EYE-VIEW THE ORIGINS ANDA BIRD EYE-VIEW THE ORIGINS AND
EVOLUTION OF DO IN THE CRANIOFACIALEVOLUTION OF DO IN THE CRANIOFACIAL
REGIONREGION
d) Progression from extra-oral to intraoral devicesd) Progression from extra-oral to intraoral devices
e) Progression from manual devices to motorizede) Progression from manual devices to motorized
devicesdevices
f) Progression from the removable fixators tof) Progression from the removable fixators to
biodegradable fixatorsbiodegradable fixators

CURRENT SCOPE OF DOCURRENT SCOPE OF DO
 Correction of Maxillo-Mandibular deformitiesCorrection of Maxillo-Mandibular deformities
a) Maxillary lengtheninga) Maxillary lengthening
b) Mandibular lengtheningb) Mandibular lengthening
c) Maxillary and Mandibular wideningc) Maxillary and Mandibular widening
d) Lengthening of the Hard palated) Lengthening of the Hard palate
e) Distraction in other cranio-facial areas.e) Distraction in other cranio-facial areas.

 Alveolar ridge augmentationAlveolar ridge augmentation
 Transport disc and TransformationTransport disc and Transformation
osteogenesis.osteogenesis.
 Dental Distraction.Dental Distraction.

 Alveolar ridge augmentationAlveolar ridge augmentation

TRANSFORMATION OSTEOGENESISTRANSFORMATION OSTEOGENESIS
The conversion of non-osseous interpositionsThe conversion of non-osseous interpositions
into normal bone by combined compressioninto normal bone by combined compression
and traction forces, sometimes augmented byand traction forces, sometimes augmented by
a nearby corticotomy.a nearby corticotomy.

BONE TRANSPORTATIONBONE TRANSPORTATION
The regeneration of intercalary bone defects byThe regeneration of intercalary bone defects by
combined distraction and transformationcombined distraction and transformation
osteogenesis.osteogenesis.
i.i. Bifocal transportationBifocal transportation
ii.ii. Trifocal transportationTrifocal transportation

BONE TRANSPORTATIONBONE TRANSPORTATION

TISSUE CHANGES FOLLOWING DOTISSUE CHANGES FOLLOWING DO
a.a. Skeletal changes – Formation of RegenerateSkeletal changes – Formation of Regenerate
b. Soft tissue adaptations – Distractionb. Soft tissue adaptations – Distraction
HistogenesisHistogenesis

HISTOLOGIC CHANGESHISTOLOGIC CHANGES
• During latency phase – formation of a fibrousDuring latency phase – formation of a fibrous
bridge.bridge.
• During distraction phase – distinct zones seenDuring distraction phase – distinct zones seen

BIOCHEMICAL FEATURES OF REGENERATEBIOCHEMICAL FEATURES OF REGENERATE
• Increased levels of alkaline phosphate, pyruvicIncreased levels of alkaline phosphate, pyruvic
acid.acid.
• TGF- Beta 1 levels increase upto theTGF- Beta 1 levels increase upto the
consolidation phase; Osteocalcin after theconsolidation phase; Osteocalcin after the
consolidation phase.consolidation phase.

• NeovascularizationNeovascularization
• NeomyogenesisNeomyogenesis
Atrophy seen is transientAtrophy seen is transient
SinusoidalSinusoidal
TransportTransport

• Nerve growth as during embryogenesis wasNerve growth as during embryogenesis was
reported by Ilizarov.reported by Ilizarov.
• However, studies by Block and Ippolito haveHowever, studies by Block and Ippolito have
shown mild nerve injury due to stretchingshown mild nerve injury due to stretching

• Mild pathoogic changes have been reported onMild pathoogic changes have been reported on
the TMJ by a few authors like Mc’Carthy.the TMJ by a few authors like Mc’Carthy.
These are again reversible with timeThese are again reversible with time

FACTORS AFFECTING DOFACTORS AFFECTING DO
Biologic BiomechanicalBiologic Biomechanical

BIOLOGIC FACTORSBIOLOGIC FACTORS
• AGEAGE
• SITE OF SURGERYSITE OF SURGERY
• LATENCY PERIODLATENCY PERIOD
• RATE AND RYTHMRATE AND RYTHM

BIOLOGIC FACTORSBIOLOGIC FACTORS
• Increased micromotion by increasing rhythmIncreased micromotion by increasing rhythm
causes increased vasculogenesis andcauses increased vasculogenesis and
enzymes and decreases the tissue damage andenzymes and decreases the tissue damage and
the degenerative changesthe degenerative changes

CONSOLIDATION PHASECONSOLIDATION PHASE
Assessment of new bone is by:Assessment of new bone is by:
I. Plain radiographyI. Plain radiography
ii. Quantitaive Computed Tomography (QCT)ii. Quantitaive Computed Tomography (QCT)
iii. Ultrasonographyiii. Ultrasonography
iv. Dual energy X-ray absorptimetryiv. Dual energy X-ray absorptimetry

Assessment of new bone by Plain radiographyAssessment of new bone by Plain radiography

Clinical assessment of consolidationClinical assessment of consolidation
• Distraction Consolidation indexDistraction Consolidation index
This however, is applicable to the long bones.This however, is applicable to the long bones.
• 6-8 weeks optimal in the craniofacial region6-8 weeks optimal in the craniofacial region
– SACHDEVA, COPE (1999,2000)– SACHDEVA, COPE (1999,2000)

BIOMECHANICAL FACTORSBIOMECHANICAL FACTORS
• Planning the distraction vectorPlanning the distraction vector
• Device fixityDevice fixity
• Need for ‘ Bone moulding’Need for ‘ Bone moulding’

PLANNING THE DISTRACTION VECTORPLANNING THE DISTRACTION VECTOR
VERTICAL HORIZONTAL OBLIQUEVERTICAL HORIZONTAL OBLIQUE

PLANNING THE DISTRACTION VECTORPLANNING THE DISTRACTION VECTOR

BIOMECHANICAL EFFECTS OF THEBIOMECHANICAL EFFECTS OF THE
DISTRACTION VECTORDISTRACTION VECTOR

Mandibular DistractionMandibular Distraction
INDICATIONS:INDICATIONS:
Hemifacial MicrosomiaHemifacial Microsomia
Treacher Collin Syndrome etc.Treacher Collin Syndrome etc.
TMJ ankylosis and condylar fracturesTMJ ankylosis and condylar fractures
Transverse deficiency of the mandibleTransverse deficiency of the mandible

MANDIBULAR DISTRACTIONMANDIBULAR DISTRACTION

MANDIBULAR DISTRACTIONMANDIBULAR DISTRACTION
Intra-oral DevicesIntra-oral Devices

MAXILLARY DISTRACTIONMAXILLARY DISTRACTION
TOTH – Le-Fort III osteotomyTOTH – Le-Fort III osteotomy

MAXILLARY DISTRACTIONMAXILLARY DISTRACTION

DENTAL DISTRACTIONDENTAL DISTRACTION

TOOTH MOVEMENT THROUGH REGENERATETOOTH MOVEMENT THROUGH REGENERATE
The earlier views suggested that toothThe earlier views suggested that tooth
movement should not be initiated into themovement should not be initiated into the
regenerate.regenerate.
Present views as supported by Liou and CopePresent views as supported by Liou and Cope
point out to the possibility of initiatingpoint out to the possibility of initiating
tooth movement immediately after or eventooth movement immediately after or even
during the distraction period.during the distraction period.

Our experiences with distractionOur experiences with distraction

The Orthodontist’s roleThe Orthodontist’s role
a.a. Decompensation of the dentitionDecompensation of the dentition
b.b. Planning the distraction vectorPlanning the distraction vector
c.c. Bone Moulding using intermaxillaryBone Moulding using intermaxillary
elasticselastics
d.d. Post-distraction OrthodonticsPost-distraction Orthodontics
FunctionalFunctional
FixedFixed

Currently Unresolved issuesCurrently Unresolved issues
a.a. Effects of distraction on growthEffects of distraction on growth
b.b. Limits of distraction osteogenesisLimits of distraction osteogenesis
c.c. Effects of distraction on eruption andEffects of distraction on eruption and
movement of teeth.movement of teeth.
d.d. Long term stability of regenerate bone.Long term stability of regenerate bone.

Directions for the futureDirections for the future
a.a. Refinements in the distraction protocolRefinements in the distraction protocol
b.b. Improvement in distraction devicesImprovement in distraction devices
c.c. Enhancement of regenerate maturationEnhancement of regenerate maturation

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Distraction osteogenesis

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