this is a presentation on Distraction Osteogenesis of Facial bones from a view point of Maxillo-Facial Surgeon

1. DISTRACTION OSTEOGENESIS
By: Dr Rayan M
Moderator: Dr M E Sham

2. •Introduction
•History
•Biologic basis
•Classification
•Distraction histiogenesis
•Biomechanical consideration
•Indications
•Alveolar distraction
•Transport distraction
•References

3. • Distraction osteogenesis is the process of slow bone
expansion in which new bone is generated in an osteotomy
gap in response to tension stresses placed across the bone
gap.
• Distraction osteogenesis has been used to avoid the
problems associated with conventional surgery and to begin
correction at an earlier age

4. Introduction
• It is an biologic process of new bone formation between the
surfaces of bone segments that are gradually separated by
incremental traction.
• This process is initiated when traction force is applied to the
bone segments & continues as a long as callus tissue is
stretched.

5. History
• Mechanical manipulation of
bone has been practiced since
ancient times.
• Hippocrates initially described
traction forces on bone

6. • Chauliac (14th century)
1st to apply continuous traction for long
bone fractures.
Used pulley attached with a weight to the
leg.
• Barton (1826)
1st to perform osteotomy
• Malgaigne (19th century)
Direct bone attached apparatus
Used double hooks which were inserted
through skin into patellar segment &
connected by screw.

7. • Codivilla (20th century)
Performed 1st limb lengthening using external skeletal traction
after an oblique osteotomy of the femur.
• Gavril Ilizarov (1951)
Designed new apparatus with 2 metal rings joined with 4
threaded rods.

8. Craniofacial Distraction Osteogenesis
• Fauchard (1728)- used arch
expansion
• Resenthal (1927)- 1st mandibular
distraction using intra-oral appliance
& coined the term distraction
osteogenesis)
• Kazanjian (1930)- mandibular DO
with over the face appliance

9. • Panilarovski (1982)- histologic evaluation of bony
regenerate & found
i) Fibrous interzone in the central region
ii) Collagen fibres & capillaries become parallel to the
direction of distraction.
• Snyder et al (1973) introduced Ilizarov’s principles to
• craniofacial skeleton & performed craniofacial DO in an animal
model
Guerrero- developed hyrax type midsymphyseal mandibular
widening technique.
First clinical mandibular distraction performed and reports were
published in 1992 - 1994

10. • McCarthy- developed multiplaner mandibular distractor
• McCarthy et al (1994)- intraoral mandibular distractor
• Triaca - a true 3 directional multiaxial intraoral distractor

11. Ilizarov Limb Lengthening (1951)

12. A: Monofocal distraction is used to lengthen abnormally shortened
bones and involves separation of 2 bone segments across a single
osteotomy.
B: Bifocal distraction is used to repair a segmental defect and requires
creation of a transport disk, which is then distracted across the defect
until it docks with the opposing bony segment.
C: Trifocal distraction is similar to bifocal distraction attempts to halve
the distraction time by transporting 2 disks from opposite ends of a
defect to dock in the middle.

13. Advantages
• Avoids second site of surgery
• Avoids graft rejection, foreign body reaction.
• Augments native bone.
• Soft tissue around the bone also regenerated.
• Can increase the breadth of bone.
• Grafted bone also can be distracted.
• Rate of relapse is less.

14. Disadvantages
• Patient compliance.
• Duration of treatment is longer.
• Second surgery.
• Device failure.
• Technique sensitive.
• Meticulous planning.
• Expense of device.
• Scarring.
• Infection.
• Improper consolidation.

15. Indications
• Segmental defects
• Resorbed alveolar bone
• Mandibular hypoplasia.
• Maxillary hypoplasia.
• Palatal expansion.
• Widening narrow mandibular arch
• Craniosynostosis.
• TMJ ankyloses.
• Correction of velopharyngeal insufficiency.

16. Contraindications
• Bone disorders
• Poor patient compliance.
• Aggressive jaw tumours.
• Preexisting TMJ disorders.

17. Biologic Basis of DO
• Tractional forces generate tension stress in the intersegmentary
callus tissue.
• This creates a dynamic microenvironment which encourages
new bone formation.
• Tension stress produces changes at cellular & subcellular levels
that stimulate mesenchymal differentiation into osteoblasts.
• Tension also enhances neovascularisation invading fibrous
tissue.
• Finally endochondral/intramembranous ossification takes
place.

18. ILIZAROV DISCOVERED TWO BIOLOGIC
PRINCIPLES OF KNOWN AS THE "ILIZAROV
EFFECTS".
• The first Ilizarov principle postulates that gradual traction creates
stress that can stimulate and maintain regeneration and active
growth of living tissues.
• The second Ilizarov principle theorized that the shape and mass of
bones and joints are dependent on an interaction between
mechanical loading and blood supply

19. Clinically, DO consists of five sequential periods
1.Corticotomy / Osteotomy
2.Latency period
3.Distraction period
4.Consolidation
5.Remodeling

20. Stages of distraction osteogenesis
• Osteotomy:
- Loss of continuity
- Triggers recruitment of progenitor cells.
- Stimulates synthesis of cytokines
- Cellular modulation (osteoinduction)
- Establishment of environmental template (osteoconduction)

21. • Latency period:
- Time from bone division to onset of traction.
- Haematoma formation -> converts to clot -> necrosis of # ends
-> neoangiogenesis -> restoration of blood supply -> cell
proliferation.
- Lasts for 1-3 days & then clot is replaced by granulation tissue.

22. • Distraction period-
• Traction of callus-> changes in cellular level
• Growth stimulation effect-
- Stimulates intersegmentary connective tissue thus prolongs
angiogenesis, increased fibroblast proliferation & tissue
oxygenation.
• Shape forming effect-
- Secretion of collagen fibers parallel to vector of distraction.
- Between 3rd & 7th day- capillaries grow into fibrous tissue in all
directions & supplies less differentiated cells of fibroblasts,
chondroblasts & osteoblasts.

23. • Consolidation period-
- Time between cessation of traction & removal of distraction
device.
- Fibrous interzone gradually ossifies.
• Remodeling period
- Period from application of full functional loading to complete
remodeling of new bone.
- Bony scaffold is reinforced by lamellar bone.
- Both cortical bone & marrow cavity restored.

24. Duration Fracture healing Distraction osteogenesis
7 days Endochondral bone formation Membranous bone formation
7-14 days Cartilagenous tissue resorbs,
primary neo-angiogenesis within
periosteum & less vascularized.
Initial vascularization by the
endosteal vessels followed by
neo-angiogenesis driven by
active distraction
17-20 days Fracture callus calcifies with
primary bone formation, external
callus is more vascularized than
internal callus
The central zone exhibits large
quantities of unmineralised
osteoid,
VEGF Higher Lower
Angiopoietins Angiopoietin-2 is higher Angiopoietin-1 is higher
Difference between fracture healing & distraction
osteogenesis

25. EFFECT OF DO ON VITAL STRUCTURES
Skeletal Muscles
• Sarcomere is the smallest functional unit of muscle.
• Force developed by a muscle during isometric contraction is
dependent on sarcomeric length which determines overlap
between actin & myosin filaments.
Simpson AH, William PE , Kyberd P, Goldspink G “ The response of muscle to limb lengthening. J bone J
joint surgery Br 1995, 77, 630-636

26. • During DO, fibres of attached muscles undergo incremental
gradual stretching.
• This stretches sarcomere & forces actin & myosin to slide over
each other.
• This decreases connecting bridges & compromises muscle
function.
• Sarcomere length must be maintained to preserve muscle
function.
• De Deyne PG “ Lengthening of muscle during distraction osteogenesis” IJOMS 2001 vol7 171-7

27. • Guerrissi et al. performed bilateral mandibular lengthening in
rabbits and evaluated soft tissues histologically and observed an
increase in metabolic and synthetic activities of surrounding
muscles.
Guerrissi J, Ferrentino G, Margulies D, Fiz D. Lengthening of mandible by dis-traction osteogenesis:
experimental works in rabbits. J Craniofac Surg 1994;5:313

28. • Fisher et al. reported that muscles aligned in a plane parallel
to distraction force showed compensatory regeneration
whereas muscles that aligned perpendicular to force of
distraction showed decrease in protein synthesis and signs
of atrophy.
Fisher E, Staffenberg DA, McCarthy JG, Miller DC, Zeng J. Histopathologic andbiochemical
changes in the muscles affected by distraction osteogenesis of themandible. Plast Reconstr Surg
1997;99:366.

29. • Simpson et al analyzed effects of rate of distraction on
muscles and confirmed that slower rate of distraction
provides better muscle adaptation whereas rapid rates of
distraction are associated with necrosis, disorganization of
muscle structure and collection of significant amount of
connective tissue in the interstitium
Simpson AH, Williams PE, Kyberd P, Goldspink G, Kenwright J. The response ofmuscle on leg
lengthening. J Bone Joint Surg 1995;77:630.[71] Karp NS, Thorne CS, McCarthy JG, Sisson Sr
GS. Bone lengthening in craniofacialskeleton. Ann Plast Surg 1990;24:231.

30. Total amount of distraction
• Up to 10% lengthening, the muscle may simply stretch to
accommodate the increased length.
• On animal studies, it was demonstrated up to 15% of muscle
lengthening it was safe.
• It appears 20% lengthening remains a critical point for single level
distraction; beyond this risk of complications rises exponentially.
• Regardless the nature of the damage, the success of muscle function
recovery is dependent on rapid reestablishment of blood supply.
De Deyne PG “ Lengthening of muscle during distraction osteogenesis” IJOMS 2001 vol7 171-7

31. Peripheral nerves
Few authors have reported various abnormalities-
• Axonal swelling
• Axo-plasmic darkening
• Complete absence of myelinated fibres
• Wallerian degeneration
• Complete absence of neurologic disturbances to neurosensory
deficits in 27% to 52% of patients.

32. Amount of distraction
• On animal studies, the first 15% of lengthening was
characterized by degenerative changes of the myelinated
fibres.
• At 20% of lengthening, the same was observed in unmyelinated
fibres.
• 25-50% of lengthening resulted in periaxonal disruption of
myelin.
Wang xx et al “effect of distraction osteogenesis on nerve : An experimental study in monkeys” Plast reconst
surg 2002 june 109 (7) 237-83

33. VESSELS
• The vascular morphogenesis during DO proceeds via
consecutive processes of arteriogenesis in the surrounding
muscular tissue.
• There is a subsequent vascular in-growth into the intraosteal
space and in the region immediately peripheral to the bone.
• The vessel volume and vessel connective density increased
between the earliest and latest time-points.
• Elise F. Morgan et al Vascular Development during Distraction Osteogenesis int Joournal of Bone. 2012
September ; 51(3): 535–545

34. • The vessel thickness increased during the period of active
distraction.
• There is an increase in the proportion of smaller vs. larger
vessels, concomitant with a decrease in a characteristic
distance between vessels, between the active distraction
and consolidation periods.

35. • Arteriogenesis is followed by angiogenesis during vascular remodelling.
• Arteriogenesis has been shown to increase circumferential stress on the
vascular walls or altered flow that generates increased shear stress on
endothelial cells.
• Active distraction initially produced an increase in size of the existent
vessels but did not initially increase the number of new smaller vessels

36. Temporomandibular Joint
• From a biomechanical point of view, it is important to consider the
various parameters influencing the TMJs during distraction
osteogenesis.
• These biomechanical parameters include
a)Movements within the intrinsic architecture of the joint,
b)Restrictions imposed by the soft tissue envelope & the load
characteristics, particularly of the articular surface

37. • Compression of condyle against glenoid fossa following mandibular
osteotomy & distraction of the mandible during orthognathic surgery
have been shown to result in adaptive as well as degenerative
changes in TMJs.
• Compression  degenerative alterations in TMJ  relative,
impairment of joint function.
• Initial disturbances  associated with adaptive joint remodeling and
subsequent growth stimulation.
• Joint may functionally adapt to the changing mechanical
environment by altering its structural integrity.

38. Harper RP, Bell WH, Hinton RJ, Browne R, Chekashin AM & Samchukov ML: Reactive changes in the
temporomandibular joint after mandibular midline Osteodistraction; Br. Journal of Oral & Maxillofac Surg,
35:20, 1997
• Harper et al. conducted a study was to evaluate the histologic
changes within the condyle in response to mandibular widening of
symphyseal region.
• Distraction of 3-5 mm was done. The appliances were then stabilized
for a period of 4 weeks.
• Non-decalcified sagittal sections of the lateral, middle and medial
thirds of the condyles were analyzed.
• Histologic changes were seen to occur in the fibrous layer,
cartilaginous layer and cartilage/bone interface.
• The severity of these changes were correlated with the likely
rotational forces directed at the condyle on the postero-lateral and
antero-medial surfaces

39. Harper RP, Bell WH, Hinton RJ, Browne R, Chekashin AM & Samchukov ML:
Reactive changes in the temporomandibular joint after mandibular midline
Osteodistraction; Br. Journal of Oral & Maxillofac Surg, 35:20, 1997

41. The biologic process of osteogenesis is largely determined
by four major interacting factors
Distraction
Forces
Fixator
stiffness
Osteogenesis
Physiological
loading
Soft tissue
properties

42. Histologically the distraction gap had 4 zones
• Central zone of fibrous tissue
• A zone of extending bone formation
• Zone of bone remodeling
• Zone of mature bone

43. Mechanism of new bone formation during
DO
• DO has been increasingly used in OMFS to treat bone defects.
- Maxillofacial skeleton has a more complex anatomic structure.
- Bones are short & flat, whereas the extremities of the axial
bones are long and tubular.
-

44. • Study by Minoru Veda et al in vitro, have described two
mechanisms of bone formation during distraction.
• Intramembranous ossification with direct formation of new
bone and
• Endochondral ossification – which the cartilage is formed and
replaced by bone through vascular invasion of the capillaries.
• Endochondral ossification at 0.5mm/day
• Intramembranous ossification at (1.0 mm /day)

45. Vector
• Vector is the direction in which segment is moved.
• Three types
a) Vertical
b) Horizontal
c) oblique

46. • The distractor vector defines the desire direction that the
distal segment must move during lengthening.
• Factors that affect the vector include osteotomy design and
location, device orientation, masticatory muscles influence,
occlusal interferences, device adjustment and orthodontic
applied forces.
• The orientation of device is the primary factor that influences
the vector. Ideally devices should be parallel to vector desired.

48. DIRECTION OF DISTRACTION
If only ramus or body is deficient - unidirectional device.
If both ramus & body lengthening is required - device is
placed at an angle, derived by the formula
PIN PLACEMENT ANGLE =1800 - GONIAL ANGLE X ramus
deficiency

49. AMOUNT OF DISTRACTION
can be determined by simply drawing a triangle:
BODY DEFF
RAMUS
DEFF
AMOUNT OF
DISTRACTION
Amount of distraction= Dc+Dr - 2(Dc x Dr) x cos A

50. Classification of distraction devices
I. According to site
• Maxillary
• Mandibular
1) Symphysis
2) Body
3) Ramus
• Alveolar
1) Vertical
2) Horizontal
3) Combined
• Palatal
• Craniofacial

51. II. According to vectors
• Univector
• Bivector
• Multivector

52. III. According to placement of distractor
• Intraoral
• Extraoral

53. IV. According to anchorage
• Tooth borne
• Bone borne

54. V. According to number of sites neoosseogenesis
• Monofocal
• Bifocal
• Trifocal
• Tetrafocal

55. VI. Depending on site where
tensional stress was induced
• Callotasis – distraction of fractured
callus
• Physeal distraction – distraction of
bone growth plate
1. Distraction epiphysiolysis – rapid
separation resulting in fracture of
epiphysis
2. Chondrodiastasis – slower distraction
allowing stretching of growth plate
without fracture

56. Distractor device
• It is the device used to push the two osteotomised segments
away from eachother
• It also holds the segments rigidly in place.
• Made of titanium, stainless steel or resorbable.

57. Parts
• Fixation plate/foot plate
• Distraction screws
• Activation arm
• Activation screw driver
• Stabilisation arm
• Vector manipulating knobs

58. Device selection
External device offer excellent control of bone segment
movement and are available in longer lengths. They are
much easier to place and remove.
Internal devices aesthetically acceptable. However they are
difficult to place. Require second surgery to remove the
device

59. DISTRACTION OF MANDIBLE
A: RAMUS OSTEOTOMY
B: ANGULAR OSTEOTOMY
C: CORPUS OSTEOTOMY

60. DISTRACTION OF MANDIBLE

61. Indications of DO
• Mandibular Distraction
• Transverse Distraction:-
- Narrow V shaped arch
- Scissors bite
- Impacted anterior teeth
- Anterior teeth crowding

62. • Sagittal Distraction:-
- Mandibular advancement in syndromic cases (Pierre Robin
Syndrome)
- Obstructive Sleep apnea
- Pre-surgical TMJ degenerative disease
- Inadequate mandibular anatomy
- Secondary advancement

63. • Vertical Distraction:-
- Hypoplasia due to trauma/ankylosis
- Hemifacial microsomia
- Reconstruction of jaw defects

64. Restoration of vertical ramal height-
• Vector should be parallel to the ramus & perpendicular to osteotomy.
• When only ramus distraction is done, there is tendency to develop
posterior open bite.
• This can be corrected either by simultaneous maxillomandibular
distraction or lefort I osteotomy as compensation.

65. Midface DO Devices
• External- Bone borne
• Internal- subcutaneous
• Intraoral-
- Extramucosal- tooth borne
- Submucosal- bone borne
hybrid

66. • According to distraction direction
1. Unidirectional
2. Bidirectional
3. Multidirectional
• According to site of distraction
- Lefort I, II, III
- Nasal bones
- Zygomatic bones
- Maxillary alveolus- Transverse, vertical, horizontal
Sandor GKB, Dr. Habil, Ylikontiola LP, Serlo W, Carmichael RP, Nish IA, Daskalogiannakis:
Distraction osteogenesis of midface; Oral Maxillofacial Surg Clin N Am 17 (2005) 485 – 501

68. • Maxillary Distraction
• Transverse Distraction:-
- Narrow V shaped arch
- Cleft palate cases
- Facial clefts

69. • Sagittal Distraction:-
- Maxillary hypoplasia
- Midface retrusion in trauma
- Syndromes (Mandibulofacial dysostosis)
- Failed bone grafts
- During maxillomandibular distraction.

70. • Vertical Distraction:-
- Anterior open bite due to maxillary hypoplasia
- During maxillomandibular distraction.

71. Maxillary Distraction Osteogenesis
• Application of DO to the maxilla was first performed in 1926 by
Wassmund.
• It was started as an alternative to traditional surgical methods.
• After osteotomy, 5 days of latency period seems to be sufficient.
• Distraction rate of 1-1.5/day with 2 times a day frequency of activation.

72. RED for maxilla
• Rigid external distraction of maxilla is a new technique for the
treatment of the maxillary deficiency that has a relatively low
morbidity.
• The benefits includes,
a)Larger advancements
b)Less potential for relapse
c)Simultaneous adaptation of soft tissue envelope
d)Allows adjustment for a longer period of time
e)Simultaneous maxillo-mandibular distraction for complex
anomalies.

73. Armamentarium
1) Activating and assembling screw drivers
2) Vertical bar component
3) Halo portion
4) Fixation pins

75. Distraction protocol with RED
1)Latency period- 4 to 6 days following osteotomy &
application of the device.
2)Distraction- 1 to 1.5mm/day.
3)Rigid external distraction device in place without active
distraction 2 to 3 weeks.
4)Final retention- elastic retention with face mask for 4 to 6
weeks at night time only.

76. • Complications
- Pins if not placed over the helix of the ear, over solid bone,
the screws tend to injure the dura.
- Care must be taken not to tangle the hair around the
screws-creates tension in the scalp and creates post
operative discomfort.

77. Potential advantages and disadvantages
Internal appliance
Advantages-
- Less susceptibilty to trauma,
- Esthetically well tolerated.
Disadvantages-
- Unidirectional movements
- Risk of infection
- Difficult removal
- Second procedure for removal

78. External appliance
Advantages-
1) Differential levels of distraction
2) Permits adjustment of vector
3) Removal relatively simple
4) Can be used in patients < 5 years
Disadvantages-
1) Bulky frame susceptible to trauma.
2) Loosening of pins or dislodgement
3) Scars at pin sites
4) Unable to use in infants

79. ALVEOLAR RIDGE DISTRACTION
• Block et al, described the potential of distraction
osteogenesis for ARA (alveolar ridge augmentation) using
animal experiments.
• Chin & Toth demonstrated the 1st ARA application in humans
after traumatic alveolar loss (traumatic avulsion of teeth).
• This can be done in either vertical or horizontal defect of the
ridge.

80. VERTICAL ALVEOLAR DISTRACTION
• Transport alveolar segment is translated vertically to increase
the height of the alveolar ridge.
• After raising mucoperiosteal flaps, vertical & horizontal cuts are
made in the bone & transport segment is created.
• Buccal osteotomy- device placement- lingual osteotomy
• Recommended minimal height of transport segment- 5mm
A.Rachmiel S.Srouji M.Peled Volume 30 Issue 6, December 2001, Pages 510-517
International Journal of Oral and Maxillofacial Surgery

82. • Distraction Protocol-
- Latency period: 5-7 days
- Distraction rate: 0.5-1 mm/d
- Consolidation period: 6-12 weeks
- Device removal after radiographic examination.

83. • Advantages-
- Increase in the height of alveolar bone.
- Bone graft not required.
- Lower morbidity rate.
- Longer implant placement possible
A. Rachmiel, S. Srouji, M. Peled: Alveolar ridge augmentation by distraction
osteogenesis. Int. J. Oral Maxillofac. Surg. 2001; 30: 510–517. 2001

84. HORIZONTAL ALVEOLAR DISTRACTION
• Transport alveolar segment is translated horizontally to
increase the width of the alveolar ridge.
• After raising mucoperiosteal flaps, vertical osteotomy is done &
horizontal screws are placed in the bone & transport segment
is created.
• Same protocols as vertical alveolar distraction are carried out.

86. Indications of ADO
• Atrophic alveolar ridges due to trauma, periodontal diseases,
pathology.
• Local open bite
• Oral rehabilitation
• Developmental defect

87. Contraindications of ADO
• Patients with severe osteoporosis.
• Extreme age.
• Uncooperative patients.
• Medically & mentally challenged.

88. TRACK device
• Tissue regeneration by alveolar callus distraction- Ko’ln
• Made up of titanium & 10 & 15 mm lengths.
• Microplates molded onto sliding screw of distraction device.

89. Indications-
- >3cm alveolar defect
- Larger atrophy areas
- Edentulous segments
Contraindications-
- Vertical height < 8 mm
- Osteoporosis
- Irradiated patients

90. • Technique-
- Mucosal incision
- Minimal periosteal reflection
- Bone plates contoured to bone
- Screw attachment for each plate
- Marking of osteotomy lines & device removal
- Osteotomy
- Checking range of motion by activating 3-4mm
- Deactivated leaving 2mm gap in between

91. • Distraction protocol-
- Latency period- 7 days
- Distraction rate- 0.5 mm twice/day till desired position
- Consolidation period- 8 weeks
- Device removal & implant placement.
Advantages-
- Reliable blood supply
- Tooth vitality intact
- No periodontal problems
- Precise adjustment of segments.

92. Endosseous Distractor (LEAD)
• These are intraoral distraction
devices used prior to placement
of endosseous implants.
• Consists of-
1. Distraction rod
2. Transport plate
3. Base plate

93. Distraction protocol-
• Latency period- 7 days
• Distraction rate- 1mm/d, twice daily
• Device left in place for 1 month
• Screw removed after 1 month & plate further 1-16 weeks later.
• Implant placement.
Sudeep S,Thapliyal GK, Suresh Menon P & Ramen Sinha: Endosseous alveolar distractor
(LEAD)TM in the management of residual alveolar ridge resorption- prospective study;
J Maxillofac Oral Surg 2009 8(4):324–328

94. Complications
• Infection of distraction chamber- Prevent by prophylactic antibiotic
treatment & adequate mucosal covering.
• Fractures of transported or basal bone- Prevent by the use of very
fine blades in the osteotomy.
• Premature consolidation- Prevent by performing a complete
osteotomy & using the appropriate distraction rate and distraction
vector.

95. • Consolidation delay and absence of fibrous union- Prevent with a
correct stabilization of the distractor.
• Slight resorption of the transported fragment-
Prevent with an overcorrection of the defect of around 2 mm.
• Wound dehiscence- Prevent by smoothing the sharp edges of the
transported fragment.

96. • Distractor instability- Prevent by prior evaluation of the bone density
and distractor model used.
• Deviations from the correct distraction vector- Prevent with prior
evaluation of the thickness of the mucosa and vestibular and lingual
muscle insertions.
-
Neurological alterations- Prevent with correct localization of
osteotomy and placement of retention screws.

97. Transport Distraction
• Costantino & co-workers (1990)- demonstrated feasibility of
bone transport in canine model.
• The same group reported clinical application to restore
mandibular defect in 1995.
• Fedostov- extraoral semicircular appratus for bone transport
• Wofson (1987)- developed 1st intraoral bone transport device.

98. • After the ostoetomy, a free segment of bone (transport
segment/disk) is created & moved across defect.
• Under stress, DO occurs & bony regenerate is formed between
residual host bone & trailing end of disk.
• When disk reaches the opposing residual target bone ,
compression forces are applied at docking site & bony margins
fuse.
• Smaller defects- monofocal DO
• Larger defects- bifocal DO
• Even larger defects- trifocal DO

99. • According to Fedotov-
- Defects of 3.5-4 cm: monofocal distraction
- Defects of 4-5.5cm: bifocal distraction
- Defects of more than 5.5 cms- trifocal distraction
Fedotov SN:Dosed distraction of mandible fragments by extra-mouth apparatus in patients
with bone defects & mandible fractures. In Diner PA, Vasquez MP, Editors: International
Congress on cranial & facial bone distraction process, Paris, France, Bologna, Italy, 1997,
Monduzzi Editore

101. • Protocols-
- Wide enough transport disk (~ 15 mm)
- 2 points of fixation
- Minimal periosteal stripping
- Osteotomy
- Latency period: 5 days
- Distraction rate: 0.5mm twice/day
- Consolidation period: 6-8 weeks/ until radiographic cortical
outline
- Fibrocartilagenous cap & device removal

102. Linear Vectors in Mandibular
Reconstruction
1
4
3
2
5

104. Potential advantages of DO versus traditional
osteotomy techniques
1)Enables undertaking of large enlargements
2)Eliminates the need for the bone grafts
3)Reduces the soft tissue restrictions
4)Minimizes dead space after Monobloc advancement
5)Enables lengthening of the nasal complex.
6)Enables the advancement of mid-facial complex at an earlier
age.

105. Potential disadvantages of DO versus traditional
osteotomy techniques
1)External port for distraction appliance activation arm.
2)Second procedure required for removal.
3)Inability to simultaneously contour the distracted
segments.
4)Longer treatment time.
5)Single vector, unidirectional.

106. Complication of distraction osteogenesis :
Intraoperative complications-
• Bleeding
• Neurosensory deficits
• Less than optimum bone splits
• Improper placement/orientation of the device may
affect the final location of distal segment.

107. Intradistraction complications:
• Pin tract infections
• Pin loosening
• Device loosening and dislodgement
• Device failure
• Inappropriate distraction vector
• Pin tract formation

108. • Premature consolidation
• Cyst formation
• Coronoid process interference
• Paraesthesia
• Trismus

109. Post distraction complications:
• Failure to achieve planned result- malocclusion,
open bite,
• Blunting of gonial angle.
• Poor growth after distraction
• Delayed consolidation

110. Axial deviations
Sagittal plane
Coronal plane
Horizontal plane
Soft tissue over stretching
Blood vessels
Peripheral nerves
Skeletal muscles
Skin
Infection

111. Thank You

112. References
• Craniofacial distraction osteogenesis – Mikhail L. Samchukov, Jason B. Cope,
Alexander M. Cherkalhin.
• Distraction of cranio-facial skeleton – Joseph G. McCarthy
• Fonseca Vol 2 Orthognathic Surgery – Raymond J. Fonseca
• Contemporary Oral & Maxillofacial Surgery – Larry J. Peterson 4th Edition
• Distraction Osteogenesis of the Maxillofacial Skeleton: Clinical and Radiological
Evaluation - Mehmet Cemal Akay

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116. THANK YOU