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DISTRACTION OSTEOGENESIS

THE NEW FRONTIER

AAO 2019-Los Angeles California

Pamela R. Hanson, DDS MS

Pamela R. Hanson, DDS, MS

Orthodontic Director Cleft & Craniofacial Teams

Children’s Hospital of Wisconsin

Surgical/ Orthodontic Director, Div. of Oral & Maxillofacial Surgery,

Medical College of Wisconsin

Faculty, Marquette University School of Dentistry, Department of

Orthodontics

Private practice New Berlin and Brookfield Wisconsin

Diplomat of the American Board of Orthodontics.

Distraction osteogenesis is a process that results

in new bone formation between the surfaces of

bone segments gradually separated by

incremental traction.

The volume of soft tissue adjacent to the

generating bone is also increased

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• DO can:

– Lengthen bones

– Increase volume of bones

3- dimensionally

– Increase the soft tissue

envelope

– Decrease relapse

• Used for craniofacial

hypoplasia

Karp NS,et al. Membranous bone lengthening: a serial histological study.

Annals Plast Surg 1992:29:2-7.

• DO cannot:

– Decrease bone length

– Retroposition bones

• To Distract:– If magnitude is too great for other procedures to

be stable

– If function demands early and/or large magnitude

correction

– If stability is better with DO

– If it sets up the patient for a more stable and

precise definitive procedure at skeletal maturity

– If skill of the team can deliver an excellent result

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Diagnostic Decisions

• Timing of distraction

• LeFort I vs LeFort III

• Corticotomy/Osteotomy design in the mandible

• Internal vs External Distraction Devices

• Distal segment manipulation

• Most stable techniques/relapse/magnitude/cleft

• Most precise technique

• Risk/benefit

Diagnostic Decisions• Timing of distraction

– Based on:

• Function– Speech

– Airway

– Masticatory function/Feeding

– Facial appearance

– Psychosocial development

• Magnitude

• Canine position

Function:globe protectionairway

psychosocial developmentmastication

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Diagnostic Decisions

• LeFort I vs LeFort III

– Where is the deficiency

– Is the correction required the same at the LeFort III &/or LeFort I

level

– Early LeFort III often with the understanding that a LeFort I

orthognathic surgery may be required

required later/skeletal maturity

• Le Fort III vs Le Fort I

• The LeFort III

– Can be done at skeletal immaturity

– The distal segment extends from the orbital floor vertically to the incisal edge of the maxillary teeth.

– Distraction will decrease the disharmony by a more stable modality

– Any movement effects the entire distal segment

– At the LeFort III level there is symmetry• Therefore, cannot tolerate rotation

– At the Le Fort I level there is asymmetry • Therefore, requires rotation

• Canine substitution & Mx midline is off to the cleft side (left), therefore

will need rotation, but only at the LeFort I level

• Diagnostic decision:

– If do LeFort III prior to skeletal maturity, it obligates the patient to a LeFort I

refinement at skeletal maturity.

• Because the advancement is completed earlier, when the LeFort I is

completed it will be a smaller magnitude move, improving the stability

Mx dental midline 6mm L of facial midline Canine substitution

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LeFort III level R to L symmetry LeFort I level asymmetry

Mx midline is 4mm L of facial and Mn midline

Treatment:

LeFort III advancement at skeletal immaturityMidface/Maxilla

Orbital rims

Zygoma

Address midface A-P hypoplasia

LeFort I advancement & rotation of the Mx at skeletal maturity

Address Mx A-P hypoplasia and asymmetry

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prepost

prepost

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3.5 months

Diagnostic Decisions

• Corticotomy/Osteotomy design in the mandible

– Surgical cut must be above the angle of the mandible

to avoid obliterating the angle

Diagnostic Decisions

• Internal vs External Distraction Devices

– Different length of devices

• Less length available when placed internally– May require a second procedure

– Or, accept a less than ideal result

– Hard tissue/soft tissue ratio decreases as device moves away from the bone

• Internal distraction devices deliver a higher hard tissue/soft tissue ratio than external distraction devices.

• A longer distraction device is required if using an external device.

• Once length of distraction is determined, a device capable of delivering 2X that

length is required

– Bilateral devices and parallelism

• More difficult on internal devices

• Can induce asymmetry if not placed parallel

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ST & AT-Vector control

• R to L devices symmetric

• Vector/device placement carefully planned & placed

• Vertical vector

– increase posterior intraoral space

– Mandibular advancement is CCW rotation of the mandible

• Horizontal vector

– More direct AP advancement

– Potential for CW rotation of the Mn if posterior dental

interference

Functionairway

palatal impingementpsychosocial development

Magnitude

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post dist placement

Post distraction

post dist removal

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IR Functionairwaypalatal impingement

psychosocial development

magnitude

IR 3/28/2016

IR

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Predistraction placement

Ortho prep

During distraction

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During distraction

Post Distraction activation

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STParallel devicesVertical vector

Maintains symmetric faceMn border more harmonious

ATAsymmetric devicesHorizontal vector

Introduces facial asymmetryMn border discrepancy

Symmetric device placementsymmetric faceDental midlines on

Asymmetric device placementFacial asymmetryLeft sided fullness

Dental midlines off

Diagnostic Decisions

• Distal segment manipulation

– Understanding where you want the distal segment to end up

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Distal segment control

Force Delivery

• Elastic traction

Hanson PR, Melugin MB. Orthodontic management of the patient undergoing mandibular

distraction osteogenesis. Seminars in Orthodontics. March 1999: 5(1):25-34.

Figure 15.17 year old Aperts male undergoing

midface advancement by distraction.

a) Midface advancing.

b) Midface advancement overcorrects

occlusion in order to achieve desired

esthetic midface result. Note: posterior

dental interference and resultant openbite

c) Cl III elastics (opposite the distraction

vector) to settle the occlusion

d) Final occlusion. DO & ortho only.

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b

c d

Le Fort III DOMidface advancement

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Figure 16: 17 year old Aperts male with midface advancement. Each image is less than a week apart. a) lateral

shift of the midface with A-P correction, note midlines, b) Bite opens with posterior dental interference as the

midface is shifted left, c) improved midline, openbite improving d) Midlines & openbite improving, e) bite closing,

midlines improving, f) finished occlusion

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b

c

d

e

f

Pre DO Ortho prepDO device placementPre distraction

8 weeks post device placement

Hanson PR, Melugin MB: Orthopedic and Orthodontic Management of Distal Segment Position During Distraction Osteogenesis,

Atlas of Oral and Maxillofacial Surgery Clinics of North America, Sept 2008, 16.2, pp 273-286.

Le Fort III DOA-P DOVertical forces

Anterior openbite closure

Orbital volume increase

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Pre DO Ortho prepDO device placementPre distraction

8 weeks post device placement

Hanson PR, Melugin MB: Orthopedic and Orthodontic Management of Distal Segment Position During Distraction Osteogenesis,

Atlas of Oral and Maxillofacial Surgery Clinics of North America, Sept 2008, 16.2, pp 273-286.

Le Fort III DOA-P DOVertical forces

Anterior openbite closure

Orbital volume increase

The diagnostic decision is will verticalDistal segment manipulation be tolerated?Must consider tooth-to-lip relationship

Can the maxillary vertical position be addressedAt a later/secondary surgery?

Diagnostic Decisions

• Most stable techniques/relapse/magnitude

– Large magnitude surgical movements generally are

more stable with distraction

Pretreatment

Le Fort III-midfacedistraction

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Pre & Posttreatment

• Significant Cl III skeletal anterior openbite

• Past Hx of multiple cleft surgeries

– Compromised maxillary vascularity

– Therefore, increased risk

• Orthognathic surgery

– 3 piece LeFort I with differential impaction to level the

arch & close the anterior openbite

– Mx advancement

– Mandibular CCW rotation

• Skeletally mature

– Should be definitive surgery

– Questionable stability, due to:

• Magnitude of skeletal move

• Compromised vascularity

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Diagnostic decision

• Premaxillary vertical distraction

– More stable

– Improves vascularity

– Increases soft tissue envelop

• Level the plane of occlusion in a more stable

manner

• Followed by a single piece LeFort I

– Smaller move, more stable

8 yr 16 yr19 yr

5’14’2018

Orthodontic set upLeFort I-3 piece

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Pre DO

DO devicePlaced

DO 10 days

DO 3 weeks

Post DO deviceremoval

11/13/2018

DOComplete

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DOComplete

Goal of vertical distraction of the premaxilla in this cleft patient:

Create single plane of Mx occlusion, followed by:Orthognathic Single piece LeFort I

Increase vascularity, soft tissue & bone in an iatrogenically

compromised cleft Mx

Improve stability, decrease relapse & decease magnitude

of Mx surgical movement

Post distraction

Single Mx plane of occlusionDecreased magnitude of orthognathic surgery

Increased bone, soft tissue & vascularity

Improved stability

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Orthognathic surgery 6 months post distraction consolidation

LeFort I advancement and impaction Anterior-Ideal Mx tooth-to-lip

Posterior-to facilitate the maxillary advancement & address any

open bites posteriorly

Diagnostic Decisions• Most precise technique

– Orthognathic surgery more precise, limited by magnitude

Diagnostic decisions

• Risk/benefit

Minimal bone in Mx left posterior quadrantRisky to move Mx with the bone deficiency

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PresurgeryJN

Amniotic Band Syndrome

AsymmetricSignificant bone deficiency

Occlusal cant

Goal: Increase bone volume

Secondary surgery Orthognathic refinement

Age 14

Age 14

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Post distraction

Post distraction

Post distraction

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Pre

Post

Post distraction

Thank you

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Pamela R. Hanson, DDS, MS AAO 2019 Distraction Osteogenesis-The New Frontier Distraction Citations Classic citations The operative lengthening of the tibia and fibula. Journal of bone and joint surgery, Abbott, 1927 Ilizarov GA, Transosseous Osteosynthesis, Springer-Verlag, 1992

Snyder CC, Levine GA, et al: Mandibular lengthening by gradual distraction. Preliminary Report. Plast Reconstr Surg 51:506, 1973 Karp NS,et al. Membranous bone lengthening: a serial histological study. Annals Plast Surg 1992:29:2-7. McCarthy JG, et al. Lengthening in the human mandible by gradual distraction. Plast Reconstr Surg 1992:89:1-10. Molina F, Ortiz M:, Mandibular elongation and remodeling by distraction: A farewell to major osteotomies. Plast Reconstr Surg 96:825, 1995. McCarthy JG, et al. Lengthening in the human mandible by gradual distraction. Plast Reconstr Surg 1992:89:1-10. The molecular biology of distraction osteogenesis. Bouletreau PJ, Warren SM, Longaker MT. J Craniofacial Surg. 2002 Feb;30(1):1-11. Review. Angiogenesis during mandibular distraction osteogenesis. Rowe NM, Mehrara BJ, Luchs JS, dudziak ME, Seinbrech DS, Illel PB, Fernandez GJ The histology of distraction osteogenesis using different external fixators. Aaronson J, Harrison BH, Stewart CL, Harp JH Jr. Orthop Relat Res. 1989 Apr;241):106-16. Distraction osteogenesis: application to dentofacial orthopedics. Yen SL. Semin Orthod. 1997 Dec:3(4):275-83. Review. Hanson PR, Melugin MB: Orthodontic Management During Distraction. Sem in Ortho 1999, 25-34.

Volumetric changes of the nose and nasal airway 2 years after tooth-borne and bone-born surgical assisted rapid maxillary expansion. Nada RM, van Loon B, Schols JG et al, Eur J oral Sci. 2013 Oct:121(5):450-6. Sequential upper airway changes during mandibular distraction for obstructive sleep apnea. Woodson BY, Hanson PR, Melugin MB, Gama AA. Otolaryngol Head Neck surg 2003 Jan:128(1):142-4. Mandibular distraction osteogenesis in very young patients to correct airway obstruction. Denny AD, Talisman R, Hanson PR, Recinos RF. Plast Reconstr Surg. 2001 Aug:108(2):302-11. Osteogenesis alveolar distraction : a review of the literature. Cano J, Campo J, Moreno LA, Bascones A. Oral Surg, Oral Med Oral Pathol Oral Radiol Endod. 2006 Jan: 101(1):11-28. Epub 2005 Oct. Hanson PR, Melugin MB: Orthopedic and Orthodontic Management of Distal Segment Position During Distraction Osteogenesis, Atlas of Oral and Maxillofacial Surgery Clinics of North America, Sept 2008, 16.2, pp 273-286. Manipulating the mandibular distraction site at different stages of consolidation. Wei S, Scadeng M, Yamashita DD, Pollack H, Faridi O, Tran B, Shuler C, Yen S. J Oral Maxillofac Surg. 2007 May:65(5): 840-6. Orthopedic and orthodontic management of distal segment position during distraction osteogenesis. Hanson PR, Melugin MB. Atlas Oral Maxillofac Surg Clin North Am. 2008 Sep: 16(2): 273-86. Orthodontic management of the patient undergoing mandibular distraction osteogenesis. Hanson PR, Melugin MB. Semin Orthod. 1999 Mar:5(1): 25-34. Complications of mandibular distraction osteogenesis. Master DL, Hanson PR, Gosain AK. J Craniofacial Surg. 2010 Sep:21(5):1565-70. Soft tissue to hard tissue advancement ratios for mandibular elongation using distraction osteogenesis in children. Melugin MB, Hanson PR, Bergstrom CA, Scjhuckit WI, Bradley GT. Angle Ortod. 2006 Jan:76(1):72-6. Toth BA, Chin M:. In McCarthy JG (ed): Distraction of the Craniofacial Skeleton. Springer, New York, 1999 Block, MS, et al: Anterior maxillary advancement using tooth-supported distraction osteogenesis. J Oral Maxillofac Surg 1995:53:561;-565.

Polley JW, Figueroa A, et al: Management of severe maxillary deficiency in childhood and adolescence through distraction osteogenesis with an external, adjustable rigid distraction device. J Craniofac Surg. 8: 181-185 1997 Guerrero CA, Bell WH:. In McCarthy JG (ed): Distraction of the Craniofacial Skeleton. Springer, New York, 1999 Le Fort III distraction using rotation advancement of the midface in patients with cleft lip and palate. Hettinger PC, Hanson PR, Denny AD. Plast Reconstr Surg. 2013 Dec;132(6): 1432-41. Rotation advancement of the midface by distraction osteogenesis. Denny AD, Kalantarian B, Hanson PR. Plastic Reconstr urg. 2003 May; 111 (6):1789-99; discussion 1800-3. Dessner S, Razdolsky Y, Mandibular lengthening using preprogrammed intraoral tooth-borne distraction devices, J oral Maxillofac Surg, 57:1318-1322, 1999 Melugin MB, Hanson PR. The use of distraction osteogenesis in the treatment of obstructive sleep apnea. AAOMS 80th Annual Session, 1998 Guerrero CA, Bell WH: Mandibular widening by intraoral distraction osteogenesis. Br J Oral and Maxillofac Surg 35:383, 1997. Remmler D, McCoy FJ, O’Neil D, et al: Osseous expansion of the cranial vault by craniostasis. Plast reconstr Surg 89: 787, 1992 Eppley BL, Sadove AM, Distraction of the Orbit: Distraction of the Craniofacial Skeleton, Springer, New York, 1999. Glat PM, Staffenberg DA, et al: Multidimensional directional osteogenesis: the canine zygoma. Plast Reconstr Surg 94: 753, 1994. Chin M: Distraction Osteogenesis for Dental Implants: Atlas of Oral & Maxillofacial Surgery Clin of North America, March 1999 Guerrero,CA, Bell WH, Intraoral Distraction Osteogenesis Atlas of Oral & Maxillofacial Surgery Clin of North America, March 1999 Liou EJ Hyang CS Rapid canine retraction through distraction of the periodontal ligament, Am J Orthod Dentofacial Orthopedics 1998:114:372-381 Stucki-McCormick SU: Reconstruction of the mandibular condyle using transport distraction osteogenesis. J Craniofac Surg 8:48, 1997.

Contemporary citations Le Fort 2 Distraction with Zygomatic Repositioning: A Technique for Differential Correction of Midface Hypoplasia RA Hopper, H Kapadia, SM Susarla - Journal of Oral and Maxillofacial Surgery, 2018

A History of Orthognathic Surgery in North America RB Bell - Journal of Oral and Maxillofacial Surgery, 2018

Respiratory And Volumetric Changes Of The Upper Airways In Craniofacial Synostosis Patients M Giuditta, A Francesco, S Barbara, G Lorenzo… - Journal of Cranio …, 2019

Crouzon Syndrome: a Comprehensive ReviewC Kyprianou, A Chatzigianni - Balkan

Journal of Dental Medicine Distraction Osteogenesis for Correction of Oral and Craniofacial Deformities I Zakhary, BM Laing, M Mirkhani, H El-Mekkawi – 2017

Digital Planning in Pediatric Craniofacial Surgery SE Haber, A Patel, DM Steinbacher - Digital Technologies in Craniomaxillofacial …, 2018

Distraction Osteogenesis: A Review SS Pur

Distraction osteogenesis in the surgical management of syndromic craniosynostosis: a comprehensive review of published papers NMN Al-Namnam, F Hariri, ZAA Rahman - British Journal of Oral and Maxillofacial …, 2018

Orbit, zygoma, and maxilla growth patterns in Crouzon syndrome X Lu, AJ Forte, R Sawh-Martinez, R Wu, R Cabrejo… - International Journal of Oral …, 2018

Eruption of Maxillary Posterior Permanent Molars following Early Conventional Le Fort III Advancement and Early Le Fort III Distraction Procedures Compared to Late … MN Gonchar, JM Bekisz, BH Grayson, JG McCarthy… - Plastic and Reconstructive …, 2019

Evaluation of parental and surgeon stressors and perceptions of distraction osteogenesis in pediatric craniofacial patients: a cross-sectional survey study RS Zhang, LO Lin, IC Hoppe, AM Wes, JW Swanson… - Child's Nervous System, 2018

Applications of Distraction Osteogenesis in Oral and Maxillofacial Surgery A Rachmiel, D Shilo - Minimally Invasive Oral and Maxillofacial Surgery, 2018

The Role of Bipartition Distraction in the Treatment of Apert Syndrome GE Glass, CF Ruff, GAJC Crombag, MHAS Verdoorn… - Plastic and Reconstructive …, 2018

Le Fort 2 Distraction with Zygomatic Repositioning: A Technique for Differential Correction of Midface Hypoplasia RA Hopper, H Kapadia, SM Susarla - Journal of Oral and Maxillofacial Surgery, 2018

What are the defining characteristics of the most cited publications in orthognathic surgery? SM Susarla, M Tveit, TB Dodson, LB Kaban… - International Journal of Oral …, 2018

Surgical Treatment in Craniofacial Malformations: Distraction Osteogenesis C Tonello, AP Peixoto, MM Yoshida, MM Brandão… - … -Orofacial Features and …, 2017

Distraction osteogenesis part 2: technical aspects S Barber, L Carter, C Mannion, C Bates - Orthodontic Update, 2018

Development of a new three-directional distractor system for the correction of maxillary transverse and sagittal deficiency CY Asan, N Kütük, G Kurt, A Alkan - Journal of Cranio-Maxillofacial Surgery, 2017