PamelaR,Hanson,DDS,MSToDistractornotDistractintheSurgical/Orthodontic

I. DefinitionofDistractionOsteogenesisa. Distractionosteogenesisisaprocessthatresultsinnewbone

formationbetweenthesurfacesofbonesegmentsgraduallyseparatedbyincrementaltraction.

b. Thevolumeofsofttissueadjacenttothegeneratingboneisalso

increasedc. Histiogenesis

i. occursindifferenttissues:ii. bone,skin,fascia,bloodvessels,nerves,muscle,ligament,

cartilage&periosteum.Melugin MB, Hanson PR, Bergstrom CA, Schuckit WI, Gerald Bradley T. Soft tissue to hard tissue advancement ratios for mandibular elongation using distraction osteogenesis in children. Angle Orthod. 2006 Jan:76(1):72-6

II. UnderstandingDistractionOsteogenesisa. Whatitcanandcan’tdo

i. Cando:1. Lengthenbones2. Increasevolumeofbones3-dimensionally3. Increasethesofttissueenvelope4. Decreaserelapse

Lineardistractiondevice(above)

(below)3dimensionalvolumeincreaseofrightsideofdogmandiblefollowingdistractionutilizingtheabovelineardistractiondevice

imagesfrom:

KarpNS,etal.Membranousbonelengthening:aserialhistologicalstudy.AnnalsPlastSurg1992:29:2-7.

ii. Cannotdo:1. Makebonesshorter2. Makebonessmaller3. Movebonesbackwards

III. ToDistractornotdistractisthequestiona. ToDistract-Whentoconsiderdistractionasatreatmentmodality

i. Ifmagnitudeistoogreatforanyotherprocedureii. Iffunctiondemandsearlyand/orlargemagnitudecorrectioniii. IfstabilityisbetterwithDOiv. Ifitsetsupthepatientforamorestableandprecisedefinitive

procedureatskeletalmaturityv. Ifskilloftheteamcandeliveranexcellentresult

b. NottoDistract-Whendistractionisnottherecommendedoptioni. Ifmagnitudeisnotgreatandotherproceduresaremoreprecise.

ii. Ifskeletalcorrectionrequiredistoretropositionaboneordecreaseskeletalvolume

iii. Ifnofunctionaldeficitiv. Ifotherproceduresprovidegood/betterstabilityv. Ifskilloftheteamcannotdeliveranexcellentresult

1. Surgicalskill/experienceinadequate2. Skilledorthodontistunavailablefor:

a. Treatmentplanningb. Monitoringtheactivedistractionc. Manipulatingthedistalsegment

vi. IfapatientisincapableofcooperationIV. TeamEffortisrequiredtosuccessfullycompletedistraction

a. Diagnosisi. Identifyingthedeficiency

1. Skeletal2. Softtissue

ii. Identifylocationofthedeficiencyiii. Identifythedifferencesbetween:

1. Volumea. 3dimensionalvalue

2. Locationa. Advancingaskeletalstructure(A-P)b. Placingthedistalsegmentinaprecise

3dimensionallocationc. Verticallymanipulatingtheskeletalstructure

i. Improvesoverallresultii. ie:LeFortIIIadvancement

1. Improvesocclusion-ieclosesanterioropenbite

2. Increasesorbitalvolumeverticallybyloweringtheorbitalfloor

predistraction

postdistraction

predistraction

early distraction prior to orthopedic mgmt

late distraction during orthopedic mgmt

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.

b. Surgicalskilli. Accuracyincorticotomy/osteotomy

c. Deviceplacementi. Accuracyinplacementpositionii. Symmetry-ifbilateraldeviceplacementiii. Idealvectorestablished

d. Protocol-shouldbecarefullyfollowedtomaximizeoutcomei. Ilizarov-1949-1stprotocolwithlowmorbidity

1. Latencyperioda. 5-7dayspriortodeviceactivationb. Fibrovascularmatrixformation

2. Rate/rhythma. 1mm/dayb. 1mm/daycompletedbyseveralincrementsper

day3. Consolidation

a. Length-Roughlytwicetheofnumberofdaysofactivation

b. Whenradiographicevidenceofboneconsolidation

e. Activedistractioni. 1mm/day

f. Controlofdistractioniscruciali. Preparation

1. Treatmentplana. Determinefinalpositionofboneb. Determinemagnitudeofdesireddistractionin

mmc. Determinelengthofdistractiondeviceatleast2X

thatofthedesiredlengthofdistractioninmm2. Orthodonticpreparation

a. Anchoragei. Toprovidetheopportunitytomanipulatethedistalsegment

b. Distractionstabilizationappliancesi. Toprovidemultipleplacesforelastictraction

ii. ToprovidemaxillaryexpansionPRN

HansonPR,MeluginMB.Orthodonticmanagementofthepatientundergoingmandibulardistractionosteogenesis.SeminarsinOrthodontics.March1999:5(1):25-34.

g. Duringdistraction-controliscrucial

i. Activationofthedistractiondevice1. Millimetriclengthening-linear2. Devicemanipulationonlyifdevicesismultidirectional

ii. Forces/manipulationofthedistalsegment1. Elastictraction2. Maxillaryexpansion

h. Afterconsolidationi. Elastictractionii. Maxillaryexpansioniii. Occlusalplanecorrectionviaadjustedbiteblock(figurebelow)

1. Sequentialadjustmentofthebiteblocktopromotesequentialeruptionofthemaxillaryposteriorteeth

2. Closestheposterioropenbitecreatedbydistractionofthemandibletothedesiredverticalbysupereruptingthemaxillaryposteriorteethtocorrectthemaxillaryocclusalplaneandclosethedistractioncreatedopenbite.

IllustrationbyDrBarryGrayson

i. Requirementsi. Cooperationbythepatientcrucialii. Teamtreatment-control/forcescanbeplacedbysomeone

whowillassumethatrole1. Educatepatientandfamily2. Monitorcloselytheadvancing/evolvingdistraction

iii. Knowledge/experienceonhowtodiagnose,deliverforcesandmonitor

V. Parameterswhenconsideringdistractionasatreatmentoptiona. Magnitude

i. Determiningmagnitudehelpsdeterminethefollowing:1. Ifdistractionisthebestmodality

2. Devicetype3. Devicelength

b. Timingi. Timingbasedonfunctionalneedii. Timingbecausemagnitudesogreatasingledefinitive

procedurewouldnotbesuccessfuliii. Timingasthefirststeptoa2stepdefinitive

surgical/orthodonticplanc. Functionaldisordersthatdrivetiming

i. Airway,ii. Masticatoryfunction-Chewing/feedingiii. Speechiv. Facialappearancev. Psychosocialdevelopment

d. Therapeuticbenefite. MaxillaryDOafteralveolarcleftgraftasmaxillaissinglepiecepost

graftVI. UniquetoDistraction

a. Shapeformingeffectb. Alteredphenotypicexpressionoffibroblasts

c. Fibroblasts“polarize”orientingparalleltothevectorofdistraction

i. Changesthedirectionofthefibroblastorientationii. Thisinturnchangesthephenotypicexpressionofthe

fibroblastiii. Whichchangestheshapeoftheboneandultimatelythe

positionofthebone

d. Forcesplacedonthedistalsegmentduringdistractione. TypesofforcesHansonPR,MeluginMB.Orthodonticmanagementofthepatientundergoingmandibulardistractionosteogenesis.SeminarsinOrthodontics.March1999:5(1):25-34.

i. Distractiondeviceactivationoralterationofamultidimensionaldistractiondevice

ii. Elastictraction

iii. Headgeariv. Expansionappliancesv. Distractionstabilizationappliances

VII. Maxillaryhypoplasiaa. LeFortIII/midfacedeficienciesb. LeFortI/maxillarydeficiencies

VIII. UnilateralMandibulardistractionIX. BilateralMandibulardistraction

PamelaR.Hanson,DDS,MSOrthodonticDirectorCleft&CraniofacialTeamsChildren’sHospitalofWisconsinSurgical/OrthodonticDirector,Div.ofOral&MaxillofacialSurgery,MedicalCollegeofWisconsinFaculty,MarquetteUniversitySchoolofDentistry,DepartmentofOrthodontics,DiplomatoftheAmericanBoardofOrthodontics.Citations:AAOToDistractorNotDistract

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