Advantages of symphyseal distraction in the treatment of … a local anesthetic, an incision from...

DOI: 10.1051/odfen/2013307 J Dentofacial Anom Orthod 2013;16:405� RODF / EDP Sciences

1

Article received: 03-2013.Accepted for publication: 05-2013.

Advantages of symphysealdistraction in the treatmentof Brodie’s Syndrome

Christine SAUVE1, Thomas WOJCIK2, Joel FERRI3

1 Doctorate of Dental Medicine, Master’s degree in Science, Fellow of the Royal College of Dentists of Canada

2 MD

3 MD, PhD

ABSTRACT

Orthodontists and maxillo-facial surgeons are very aware of the differenttherapeutic options for the correction of maxillary transverse deficiencies. Butwhat about mandibular transverse deficiencies? A number of dentofacialorthopedic mandibular expansion techniques have been suggested, but theyoften have a tendency to relapse. Symphyseal distraction is the easiest solutionfor the correction of mandibular transverse defects, particularly in cases of amajor deficiency such as Brodie’s Syndrome. In addition to recreating aphysiologic occlusion, this technique makes it possible to considerably increasethe width of the bony and soft tissue that not only improves the patient’sfunction and esthetics, but also helps to ensure long-term occlusal stability aswell.

KEY WORDS

Brodie’s syndrome

Symphyseal distraction

Mandibular widening

DEFINITION AND CLINICAL SIGNS

Brodie’s Syndrome, also known as ‘‘scis-sors-bite,’’ is a transverse anomaly of the

jaws. The two causes, excessive maxillarywidth and excessive mandibular narrowing,

Address for correspondence:

Christine SAUVECHU de Quebec, Hopital de l’Enfant Jesus, 140118e rue, Quebec (QC),Canada G1J [email protected] available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2013307

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have been described but they do notexclude simultaneous affliction ofboth arches,1,6. It should be notedthat the maxilla is affected less fre-quently3.

Brodie bite can be found in 1 to1.5% of the population (Fig. 1)16.Patients suffering from this syndromehave a Class I or Class II occlusionwith either uni- or bilateral maxillarycomplete buccal crossbite19. Sincethere are no posterior occlusal con-tacts to be found, the premolars andmaxillary molars are over-erupted andcompletely hide their antagonists(Figs. 2-3). In addition, a linguoversionof the lower molars is regularly seenalong with an accentuated Curve ofWilson16. Other clinical signs that canbe found are a deficit in the transversemandibular width, a reduction in thearch length and in the inter-caninewidth and a crowding in the mandibu-lar incisor-cuspid area.

During the clinical examination,the practitioner must look for anocclusion in centric relation of thecondyles in order to avoid a diagnos-tic error of a crossbite28. In effect,since the patients do not have astable occlusal position because ofthe absence of molar contacts, afunctional lateral crossbite can bepresented. Study of dental casts isequally important, because it allows

Figure 1Brodie’s Syndrome. Photos

before treatment.

Figure 2Brodie’s Syndrome - Frontal view.

Note the complete bilateral posterior crossbite.

CHRISTINE SAUVE, THOMAS WOJCIK, JOEL FERRI

2 Sauve C. Advantages of symphyseal distraction in the treatment of Brodie’s Syndrome

to check if simultaneous mandibularadvancement will correct the abnor-mal transverse dimension8.

The main complaints of these pa-tients are functional. This severe mal-occlusion leads to masticatorydifficulties related to the absence ofcontacts but equally to interferencesfound during elocution movements.In addition, the over-eruption of the

Figures 3a & bBrodie’s Syndrome – Lateral views.

Note the complete crossbite with tissue contact,characteristic of Brodie’s Syndrome. There is also alack of oral hygiene.

Figure 3cPanoramic pre-treatment x-ray.

Note the lower canine-to-canine crowding.

Figure 3dPre-treatment profile x-ray. Note an anterior deep bitewith palatoversion (linguoversion) of the upper inci-sors, together they are characteristic of a Class IIBrodie’s Syndrome.

ADVANTAGES OF SYMPHYSEAL DISTRACTION IN THE TREATMENT OF BRODIE’S SYNDROME

Rev Orthop Dento Faciale 2013;16:405. 3

posterior teeth affects the periodon-tium and can injure the neighboring

soft tissues, causing a not insignifi-cant functional annoyance6.

TREATMENT OPTIONS

To correct the malocclusion, manytreatment options were proposed.They include dental extractions, inter-proximal reduction and orthodonticcompensation. The last option coulddamage the periodontium, particularlyif there is a vestibuloversion of thelower anterior teeth, because itforces the teeth out of their alveolarbone14. Using intermaxillary elasticsto create a vestibuloversion of themandibular molars and a linguover-sion of the maxillary molars also hasa role in our therapeutic arsenal19.However, this leads to a non-physio-logic interdental angulation. The pro-blem with all of these therapies isthat they allow dental and alveolarexpansion without any bone augmen-tation in the mandible. Moreover, allthe approaches to increase archlength and the mandibular intercaninewidth are often subject to relapse, asstipulated by Profitt27. ‘‘Expansion’’thus created is not only very un-stable, but it also compromises theesthetics of the smile by modifyingthe black triangles of the buccal corri-dors7,4,14,19.

Interproximal reduction has certainlimits relating to the degree ofcorrection that can be obtained.Since Brodie’s Syndrome is a severemalocclusion, it is rare that one ther-apy alone will correct the problem.As for dental extractions, they makeit possible to recreate satisfactoryocclusal contacts, but often lead to a

morphologic alteration that is notnegligible10,21.

To treat the increased maxillarywidth, some authors have suggestedpalatal constriction, such as a seg-mental Lefort I osteotomy. This moredelicate technique only allows forconstriction of about five to six milli-meters by resecting the bone be-tween the segment. This approachrisks damage to the palatal mucosaand creation of an oral-antral commu-nication3,4.

Other options are possible. Forexample, osteotomy to enlarge themandible, as a treatment for a con-stricted mandible, is described. Infact, this surgery consists of a surgi-cal separation at the mandibular sym-physeal midline. Following, thefragments are positioned by rota-tional and translational movements atlocations and are stabilized with thehelp of plates and screws. A bonegraft is also necessary in order to fillthe gap defect that is created at theosteotomy site. This technique hashowever been abandoned in light ofthe increased number of gingival de-hiscences, of periodontal problemsand of relapses4,8,11,25.

Since all these options present anumber of disadvantages, such as in-stability or esthetic compromise,symphyseal distraction is an alterna-tive treatment to consider in the cor-rection of Brodie’s Syndrome.



SYMPHYSEAL DISTRACTION

This distraction technique is utilizedin order to increase the transverse di-mension of the symphysis. It pre-sents a certain advantage when thedentoalveolar or skeletal anomalycannot be corrected by traditionalorthodontic therapies. These trans-verse deficits are found in an under-developed symphysis, in cases ofsignificant lower incisor overlapping,in syndromic malocclusions such asPierre Robin, Franceschetti and ofcourse, Brodie’s Syndrome2,9,12,31.

Osseous distraction is a procedurethat allows the creation of new bonebetween two osseous segments thatare gradually separated by traction.The lengthening of the formed callus,or callotasis, is achieved progres-sively by daily activations of the dis-traction device. The mineralization ofthe callus is initiated after the thirdweek following the end of activations(consolidation period)2,7.

At the beginning of the 1950s, Ili-zarov described the technique of oss-eous distraction on long bones andextolled its many advantages for os-teogenesis and tissue growth.McCarthy was the first to applythese principles on the human mand-ible in 198924 and a few years laterGuerrero used it in the correction ofsymphyseal transverse deficien-cies7,14,31. They noticed that theachieved expansion takes place notonly in the alveolar bone, but also inthe basal bone and surrounding softtissues. In addition, they observedthat the expansion created by sym-physeal distraction was not propor-tionate, namely the expansion wasgreater in the canine areas than inthe molar areas7,19,23. Because ofthis, due to the transverse and ante-rior-posterior growth achieved, therewas an increase in the length of thearch and a change in its shape, goingfrom a ‘‘V’’ to a ‘‘U’’7,9,11.

ASSESSMENT AND SURGICAL TECHNIQUE

Given that mandibular symphysisfuses around the first year of life, theprocedure of symphyseal distractioncan be performed on a patient duringthe growth phase, as soon as the in-cisors and the permanent mandibularcanines erupt, and on adults11. Be-fore planning this type of surgery, acomplete oral and dental examinationis mandatory. Checking for any pre-vious medical history, performing anocclusal dental analysis, assessingthe periodontal health and the stateof the temporal-mandibular joints,

studying the moulages and takingxrays are all indispensable elementsfor preoperative evaluation. A panora-mic xray makes it possible to assessthe position of the dental roots. If sig-nificant dental crowding is also pre-sent, cone-beam is an invaluable toolfor optimal visualization. Someauthors have suggested that ortho-dontic treatment during the preopera-tive period needs to be started inorder to create a divergence of theroots and/or a sufficient space nearthe osteotomy tract planned by the



surgeon10,21,26. These precautionsmake it possible to avoid injuries tothe dental roots and the periodontalligament, particularly if the availablespace is insufficient. Moreover, thisfosters the formation and normalgrowth of a high quality bone. In fact,it has been shown that if the osteot-omy leads to exposure of the root,the osseous formation cannot beachieved on the tooth. The presenceof bone on both sides of the osteot-omy is therefore desirable in order tooptimally induce osteogenesis2,4. Be-sides, it is sometimes necessaryto open the observed overbite ofBrodie’s Syndrome in order to allowfor an expansion without occlusalinterference. This can be achieved bythe placement of molar bite raisers(bite turbos)6,9.

Symphyseal distraction can bedone on an outpatient basis, witheither general anesthesia or con-scious sedation9,14,29. After injectionof a local anesthetic, an incision fromcanine to canine through the mucosaand muscle of the oral vestibule ismade using a cold or electric scalpel.A subperiosteal dissection follows onthe anterior face of the symphysisuntil the mental foramina are visible.Identifying the dental apices makes itpossible to direct the position of thedistraction device. It must be posi-tioned parallel to the ideal plane ofdistraction that in most cases, corre-sponds to the occlusal plane. In fact,since the connective tissue fibers in-side of the callus are laid out parallelto the direction of the forces of dis-traction and since a translation move-ment is desired, it is important thatthe callus be as parallel as possible

to the reference plane. In addition,the device must be placed very closeto the point of resistance in order toachieve a symmetrical apposition. Ifthis isn’t the case, other force vec-tors will be induced with an asymme-trical osseous apposition and arotation of the segments2,10,11.Therefore, it is of the utmost impor-tance to pay particular attention tothese details, because the placementof a distractor has an impact on theshape and the direction of the bonethat will be created (Fig. 4).

Adapting the distraction device willbe easier on a continuous mandible.Therefore, it is advisable to insertsome screws to mark the ideal posi-tion once the symphyseal disjunctionis completed. When the distractor isremoved, a vertical osteotomy, begin-ning at the basal edge and stoppingat the alveolar bone, is performedwith a saw or a piezotome3. The useof osteotomies completes the sym-physeal division between the dentalroots (Fig. 5).

The scoreline is usually made be-tween the two central incisors, but itcan be off-centered in the parasym-physis in order to correct an asym-metry. It can also be shaped like astaircase step and still keep the cutcentered on the basal bone, to dimin-ish the risks of a dental defect or alateral deviation of the chin8. Whenthe disjunction is completed, the dis-tractor is put back into place usingthe holes already pierced into thebone as a reference. The distractioncylinder, that contains a telescopicscrew, can now be joined to theplates of the device and activationsare made to check proper functioning



and to verify the vector of distraction.Next, the mucosa is sutured above

the plates without however coveringthe cylinder (Fig. 6).

DISTRACTION

A few days after surgery, the dis-traction device can be activated. The

latency period certainly allows for thecreation of an osseous callus, but

Figure 5Complete vertical osteotomy tract.

Note the holes that serve as landmarks to relocate the distractor.

Figure 4Fitting the distraction apparatus prior to the osteotomy.



also the healing of the mucosa. Oneor several activations can be pre-scribed, without however exceedingthree millimeters a day. An exces-sively fast pace of activation lowers

the quality of the callus whereas atoo slow rate of activation can leadto a premature osseous consolidationand therefore, an insufficient expan-sion8,20,21.

TYPE OF DISTRACTOR

Several types of symphyseal dis-tractors are on the market: distrac-tors with dental supports, distractorswith osseous supports and hybriddistractors, namely osseous and den-tal supports at the same time19. Thedental distractor is usually attachedto the lingual surface of the teethand is the source of discomfort andhygiene problems. Moreover, its im-pact is more dentoalveolar than basaland it creates a labioversion of thelower incisors2,11,18. Because of this,the rate of relapse is increased sincethe alveolar expansion is notsupported by the basal bone17. Thedifference in expansion can be ex-plained by the position of the device

that is above the point of resis-tance29.

A distractor with osseous supportsis secured on the anterior osseoussurface of the symphysis and chin.This distractor makes it possible toachieve a symmetrical distraction ofthe basal bone and of the alveolarbone since it directly transmits theforces of distraction to the mand-ible8,29.

However, in the course of distrac-tion, the adjacent teeth migrate dur-ing callotasis if they are notorthodontically retained. This phe-nomenon called ‘‘walking-teeth phe-nomenon’’ is due to the elastic

Figure 6End of the operation.



traction of the transseptal fibers ofthe periodontal ligament2,14. Oncethe activations are stopped, a periodof consolidation is necessary (Fig. 7).

Some authors recommend main-taining this phase for two monthsbefore beginning orthodontic move-ments. Before the end of the periodof consolidation, they recommendthat the practitioner use xrays tocheck the quality of the osseous cal-lus formation. They stipulate that an

early movement can lead to a period-ontal defect, an osseous defect andeven the loss of a tooth8,11,13,14.Whereas others advocate an early re-activation, namely from 5 days to 2weeks following the end of the acti-vations of the device3,4,11,23, 29. Liousuggests that the orthodontist initiateorthodontic movements early be-cause the forces created acceleratethe maturation of the fibrous bonethat is produced22.

ADVANTAGES OF THE TECHNIQUE

Symphyseal distraction as a treat-ment for Brodie’s Syndrome, has anumber of advantages.

Since it is reliable and safe, it al-lows for osseous expansion as wellas expansion of soft tissues such asmuscles, subcutaneous tissues, freeand attached gingiva12,16. This versa-tile surgical technique can be

adapted to any defect including thethree axes (anterior-posterior, trans-verse and vertical)13. In addition, itallows for the extraction of thewisdom teeth, genioplasties andconcurrent expansion of the uppermaxillary9,11,14,21. Minimally invasive,this short-term procedure is predict-able and does not require any bone

Figure 7End of activations of the distraction appliance.

Note the presence of a removable device to open the deep bite.



grafting and therefore entails no mor-bidity at the donor site7-9,13. Symphy-seal distraction eliminates extractionsand compensatory vestibuloversions,and allows the practitioner to harmo-nize the arch and at the same timediminishes the risk of relapse andperiodontal complications9,13. Ofcourse, there may be mobility of theteeth close to the osteotomy sitesecondary to inflammation, but it istemporary11,16. Moreover, one of theadvantages of this therapy is thatorthodontic treatment can be simulta-neously performed with anterior dis-traction. Furthermore, no long-termneuro-sensory damage has been re-ported13,29.

However, this technique has somedisadvantages. The placement of thedistractor requires a second surgeryfor its removal and quite obviouslyadditional costs are involved for itspurchase10, 30. Even if these studiesshow that the risk is low, there is al-ways the possibility of damaging theadjacent teeth. In addition, wearingthe device can trigger chronic gingivi-tis15,29. Questions remain as to theeffect of symphyseal distraction on

the temporomandibular joints. To be-gin with, it appears that the condylemoves differently based on the typeof distractor used. Del Santo et al.suggest that when a teeth-supporteddistractor is used, it increases the in-ter-condylar distance . However, re-sults are not statistically significant11.For their part, Molkoç et al. andLandes et al. argue that there is a de-crease in this distance with hybridbone-supported distractor20,23. None-theless, temporomandibular condylesadapt easily to lateral and medianmovements given that only tempor-ary symptoms of temporomandibularjoint dysfunction have affected a fewpatients5,11,15,23. A study on mon-keys demonstrated that minor histo-logical changes occurred in thedifferent layers of the condyle, parti-cularly in areas of compression.These zones, located on the postero-lateral and on the antero-median sur-faces of the condyle constitute, infact, an adaptive response to the ro-tation of the condyles2. To date, nonotable repercussion has been foundin any of the reported studies.

CONCLUSION

Even if Brodie’s Syndrome is not acommon malocclusion, it is importantto know all the available therapeuticoptions to improve patient’s occlu-sion, function and esthetics.. Sym-physeal distraction has proven to be

a highly recommended treatment so-lution given its many advantages,particularly concerning osseousgrowth and periodontal preservation(Figs. 8-10).



Figure 8Brodie’s Syndrome.

End of Treatment photos.

Figure 9Frontal view of occlusion at the end of treatment.

Figures 10a & bLateral views of occlusion at the end of treatment.

We found a Class I canine and molar as well as a normalization of the transverse posterior occlusal relationships.The overbite has been raised. Unfortunately, the hygiene remains inadequate.



Figure 10cPanoramic x-ray after treatment. We found classical osteosynthesis along with two resi-dual screws, in the syphyseal area, that could not be removed because of a completeosseous integration. It is noted that the patient had to undergo a sagittal osteotomy ofthe ascending ramii in order to correct his mandibular retrusion.

Figure 10dPost treatment profilexray. The overbite hasbeen leveled and thenormalization of thebasal bone was com-pleted by a bilateralsagittal osteotomy ofthe ascending ramii.



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