Distraction osteogenesis, also called callus distraction, callotasis and osteodistraction, is a process used in orthopedic surgery, podiatric surgery, and oral and maxillofacial surgery to repair skeletal deformities and in reconstructive surgery

1. Use of distraction osteogenesis in orthognathic surgery
DR MAMOON MAARWAT
PG RESIDENT MDS ORTHODONTICS PGY-III
SARDAR BEGUM DENTAL HOSPITAL GANDHARA UNIVERSITY PESHAWAR

2. Contents
 Introduction.
 Biology & stages of distraction osteogenesis.
 Types of distraction osteogenesis & distractors.
 DO in preparation for orthognathic surgery.
 DO in lieu of conventional orthognathic surgery.
 Summary

3. Introduction

4. Introduction
 Distraction osteogenesis has been used for lengthening of bones since the
earlier 20th century.
 DO was adapted to the craniofacial skeleton in dogs by Snyder in 1973.
 McCarthy is credited with popularizing the technique in humans with his
1992 publication of mandibular DO in patients with
o Hemifacial microsomia and Nager syndrome.
McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH. Lengthening the
human mandible by gradual distraction. Plast Reconstr Surg. 1992;89:1–8.

5. Introduction cont…
 Advantages of distraction osteogenesis compared to conventional
technique
o Larges bony movement
o Concimitant expansion of surrounding soft tissues
o Neurovascular structures
o Greater stability
o Eliminates the need for bone graft and associated donor site morbidity
o Blood loss and hospital stay

6. Introduction cont….
 Disadvantages include
o High degree of patient compliance.
o Total treatment time.
o Potential for device failure.
o Second operation is required for device removal.
o Vector of the movement is difficult to control.

7. Biology and Stages of distraction
osteogenesis

8. Biology & stages of distraction osteogenesis
 Slow expansion and controlled microtrauma in DO
 Bone formation in DO gap occurs through intramembranous bone
formation
 Mediated by series of growth factors, cytokines & ECM proteins.
 Three stages
o Latency
o Distraction
o consolidation

9. Biology & stages of distraction osteogenesis
BONE
OSTEOTOMY CUT
LATENCY PERIOD
Primary bone callus
DISTRACTION PHASE
CONSOLIDATION

10. Types of distraction osteogenesis and
distraction devices

11. Types of distraction osteogenesis and distraction
devices
 Three types of distraction osteogenesis
1. Monofocal
2. Bifocal
3. Trifocal

12. Types of distraction osteogenesis and distraction devices
 Monofocal distraction osteogenesis:
o Simplest form of DO is the creation of a“dis-traction gap” by
slow separation of two cut bone sur-face
o Serves to augment a region of existing bone
New
Bone

13. Types of distraction osteogenesis and distraction devices
 Bifocal distraction osteogenesis:
 In this approach, a“transport segment”of bone is distracted from
one side of the defect to the other.
 Used to fill a continuity defect, after tumor resection, or construct a
missing portion of bone, as in a congenital ramus deformity.
Transport
fragment

14. Types of distraction osteogenesis and distraction devices
 Trifocal distraction:
o Trifocal DO is a modification of the bifocal technique
o Two transport seg-ments are created- one on each side of a larger
defect- and they are distracted toward one another until they meet.
o Use full in larger defects
TS TS

15. Types of distraction osteogenesis and distraction devices
 Distraction devices:
o Necessary to facilitate controlled, gradual separation of the
osteotomized segments during the distraction phase
o To stabilize segments to promote ossification during consolidation
phase

16. Types of distraction osteogenesis and distraction devices
 Choice of device based on :
o Type and location of movement planned
o Surgical access for osteotomy and device placement
o Rigidity of device needed
o Characteristic of the bone to which device is placed
o Desired vector movement

17. Types of distraction osteogenesis and distraction devices
Craniofacial distraction osteogenesis devices
Internal External
• Unirectional
• Bidirection
• multidirectional
Bone -borne
Tooth-borne
Bone-borne
Hybrid Sub-cutaneous
Intra - oral Extra-mucosal
Sub-mucosal

18. Types of distraction osteogenesis and distraction devices
 Advantages of external devices include
o Easier application and removal.
o Improved access to the device mechanism to manage malfunction
compared to internal devices.
 Disadvantages include ED may leave scars as the pins travel
through the skin, less stable, easily damaged by head movement

19. Types of distraction osteogenesis and distraction devices
 Internal devices
o Difficult to place
o Always require a second opera-tion for removal
o More stable
o Do not leave pin scars
o More socially acceptable

20. Distraction osteogenesis in Preparation
for orthognathic surgery

21. DO in preparation for orthognathic surgery
 Distraction osteogenesis techniques are useful to the orthognathic
surgeon both in coordination with and in preparation for other
orthognathic procedures

22. DO in preparation for orthognathic surgery
1. Surgically assisted maxillary expansion (SAME)
o Most common use of DO techniques prior to orthognathic surgery is
for management of maxillomandibular transverse discrepancies
o Rapid expansion is performed prior to fusion of MPS
o In adults maxillary expansion achieved only via SAME

23. DO in preparation for orthognathic surgery
 When patient presented with absolute maxilla mandibular
transverse discripency orthodontist have several options
o Orthodontic resolution of discrepancy via dental tipping.
o Non-surgical orthopedic resolution of discrep-ancy via
maxillary distraction using a tooth-borne or bone-borne device
o Surgically assisted maxillary expansion prior to fixed appliance
treatment and/or orthog-nathic surgery

24. DO in preparation for orthognathic surgery
 Advantages of a SAME procedure compared to a segmental
osteotomy include
o Equal widening of entire maxilla
o Increase in arch length
o Ability to create larger movements that can be achieved with lefort 1
osteotomy
o No need for bone grafting

25. DO in preparation for orthognathic surgery
 Advantages of a segmental Le Fort I osteotomy are
o Single rather than staged operations
o Decreased total treatment time
o Lack of creation of a temporary diastema between the central
incisor teeth, which occurs with SAME
o Slightly decreased transverse relapse rate

26. DO in preparation for orthognathic surgery
2. Distraction in congenital and acquired craniofacial deformities
o Many patients presenting for orthognathic surgery will have had prior DO for
management of congenital or acquired craniofacial deformities in child hood.
Patient with craniofacial anomalies may have had DO prior to distraction
ostogenesis these include:

27. DO in preparation for orthognathic surgery
 These include patient with
1. Pierre Robin sequence.
2. Hemifacial microsomia.
3. Midfacial distraction osteogenesis (apert, crouzan, Pfeiffer
syndromes).
4. Treacher collin syndrome.
5. Juvenile idiopathic arthritis.

29. DO in preparation for orthognathic surgery
1. Pierre Robin sequence:
Micrognathia, glossoptosis and airway obstruction & may have undergone
mandibular distraction during infancy.
In these patient orthodontist/ orthognathic surgeon must pay close attention
to:
A. Underlying diagnosis of Pierre Robin sequence
B. Potential for addition mandibular growth
C. Potential for recurrent OSA & TMJ function
D. History of Pharyngeal flap surgery

30. DO in preparation for orthognathic surgery
2. Midface deficiency syndrome:
 Lefort III and midface deficiency syndrome like
o Crouzan syndrome
o Apert syndrome
o Cranisynastosis syndrome
 Midface advancement is delayed until skeletal maturity
 Midfacial distraction is dictated by orbital glob relationship not occlusion

31. DO in preparation for orthognathic surgery

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34. DO in preparation for orthognathic surgery
3. Combined midfacial and mandibular distraction for counter
clockwise rotation in Treacher Collins syndrome.
4. Unilateral or bilateral mandibular ramus distraction in patients with
progressive mandibular resorption, such as in juvenile idiopathic
arthritis.
5. Hemifacial microsomia patient

35. DO in lieu of conventional orthognathic
surgery

36. DO in lieu of conventional orthognathic surgery
 There are some scenarios in which the orthognathic surgeon may
choose to use DO instead of conventional osteotomies for
correction of a dentofacial deformity.
 Three types of situation that frequently dictates this
I. The need for large and/or complex movements.
II. Excessive scar tissue or other soft tissue limitation to planned
movement.
III. Expected need for bone grafting with acute movement.

37. DO in lieu of conventional orthognathic surgery
 Bell and Guerrero proposed use of DO for movements exceeding
6mm in their 2007 textbook on the topic.
Bell WH, Guerrero CA. Distraction Osteogenesis of the Facial Skeleton.
Hamilton, ON: BC Decker; 2007.

38. DO in lieu of conventional orthognathic surgery
1. Maxillary DO in patients with repaired cleft lip and palate:
 Patients with repaired cleft lip and palate may have significant
maxillary hypoplasia and dense scar tissue of the lip and palate.
 There is some evidence that stability is inferior with conventional
techniques and improved with DO.
 A metaanalysis, however, did not find a significant difference in
stability between the two techniques.
Austin SL, Mattick CR, Waterhouse PJ. Distraction osteogenesis versus
orthognathic surgery for the treatment of maxillary hypoplasia in cleft lip
and palate patients: a systematic review. Orthod Craniofac Res.
2015;18:96–108.
Chua HD, Hagg MB, Cheung LK. Cleft maxillary distraction versus orthognathic surgerywhich
one is more stable n 5 years? Oral Surg Oral Med Oral Pathol Oral RadiolEndod.
2010;109:803–814

39. DO in lieu of conventional orthognathic surgery

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42. DO in lieu of conventional orthognathic surgery
2. Midface and maxillary DO in patients with hypoplasia syndromes
In patients with syndromic craniosynostosis, subcranial Le Fort III
osteotomy and midfacial distraction can be used to achieve
o Larger midfacial advancement with greater stability
o Less blood loss and without need for bone grafts and associated
donor site morbidity compared to standard techniques and bone
grafting.

43. DO in lieu of conventional orthognathic surgery

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45. DO in lieu of conventional orthognathic surgery
3. Mandibular antero-posterior DO:
 DO may also be used in lieu of conventional orthognathic surgery to
achieve large and complex mandibular movements.
 This technique is particularly useful in patients with
o Angle Class II malocclusions and severe mandibular hypoplasia
o Extreme facial asymmetry, and/or significant loss of posterior
vertical facial height requiring counterclockwise rotation of the
mandible for correction

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49. THANK YOU