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CONTENT
INTRODUCTION HISTORY BIOMECHANICAL PARAMETER BIOLOGIC PARAMETER CLASSIFICATION SEQUENTIAL PERIOD OF DO STAGES OF # HEALING EFFECT OF DO ON SKELETAL MUSCLE EFFECT OF DO ON PERIPHERAL NERVE EFFECT OF DO ON TMJ DISTRACTION DEVICES INDICATION & CONTRAINDICATION
INTRODUCTION
Samchukov et al., 1998 described Distraction osteogenesis as a biologic process of new bone formation between the surfaces of bone segments that are gradually separated by incremental traction The traction generates tension that stimulates new bone formation parallel to the vector of distraction
ILIZAROVS EXPERIMENTS
Stable fixation with preserved axial micromotion generates membranous bone formation.
Preservation of osteogenic tissue during osteotomy. Bone regenerates within the distraction gap is always formed along the vector of applied traction.
Bone formation depends on both rate and rhythm 0.5mm/day : premature consolidation
Mc Carthy & colleagues were the first to clinically apply extra oral distraction osteogenesis on four children with congenital abnormalities.
Guerrero (1990) devolped his mid symphyseal mandibular widening technique. Molina & Ortiz simplified the method of Mc Carthy - corticotomy with medial cortex intact - one pin fixation on either side
BIOMECHENICAL PARAMETERS
1. 2. 3. 4.
BIOLOGICAL PARAMETERS
1. 2. 3. 4.
5.
6.
7.
Distraction device classification DISTRACTION DEVICE CLASSIFICATION Craniofacial Distraction Devices External Internal
Bone borne
Subcutaneo us
Unidirectional device
Bidirectional device
Multidirectional device
Bone physiology
Process of bone formation is called osseogenesis Intramembranous Endochondral
6 steps of # healing: - impact - induction - inflammation - soft callus - hard callus - remodeling
Youngs Modulus for collagen is found to be approximately 1000 MPa, and after about 3-4 %
Multiple increments - higher extent of bone formation > 20,000 - chondroid formation
-Ulrich Mayer et al
increased callus formation increased osteoblast proliferation 20,000 microstrains with 10 cycles/day fast results
AUTOMATED DISTRACTORS
-Ulrich Mayer et al
OSTEOTOMY
Division of bone in two segments Triggers bone healing ( # healing ) - recruitment of osteoprogenitor cells - osteoinduction
- osteoconduction
LATENCY PERIOD
Period from bone division to onset of traction Represents time allowed for callus formation Sequence of events -Hematoma
-Clot
-Bone necrosis at the ends of # segments
Ingrowths of vasoformative elements & cellular proliferation Stage of inflammation ( 1-3 days ) clot is replaced by granulation tissue
# segments.
granulation tissue is converted to fibrous tissue
- it depends on many factors like: cytokines and growth factors - role of callus formation Enlarges the diameter of segments Serves as solid base for new bone formation
DISTRACTION PERIOD
Application of traction forces to osteotomised bone segments.
Normal # healing:
-fibrocartilagenous tissue of
Distraction :
-normal process of healing is interrupted by application of gradual
microenvironment.
- changes at cellular and sub cellular level - growth stimulating effect - shape forming effect
vector of distraction.
- soft callus becomes longitudinally oriented along the axis of distraction
Between 3-7 day of distraction capillaries grow into fibrous tissue During the 2nd week of distraction primary treabeculae begins to form
Osteogenesis is started at existing bone wall and progress towards the center of distraction gap. By the end of 2nd week osteoid begins to mineralize
CONSOLIDATION PERIOD
Time between cessation of traction and removal
of distraction devices.
This period represents the time required for
complete mineralization
membranous ossification.
Muscle orient in a plane parallel to distraction force & adapt with compensatory regeneration. ( Guerrirre & co workers )
Diminishes the number of connecting bridges between actin and myosin, compromising muscle
function.
To preserve muscle function
Slower rate leads to good muscle adaptation but early consolidation. Maintain the balance.(.75mm 1mm per day) More fractioned rhythm leads to less muscle injury Mizumoto & coworkers
Amount of distraction: 10%-12% - no damage (only stretching) 10%-20% - muscle growth >20% - irreversible muscle damage 20% - critical point Nerve supply Blood supply
Inferior alveolar nerve injury direct - intraoperative manipulation - contact with fixation devices indirect - compression by postoperative odema - constriction of medullary canal
Adaptation of peripheral nerves to distraction peripheral nerve trunks are highly resistant to stretching
15% lengthening - early degenerative changes of myelinated nerves, swelling of schwan cells
No acute injury with 10 mm distraction Mild IAN changes in 10-15 % nerve fibers - samchukov et al
Distraction devices
Bidirectional devices
allows distraction in two directions as well as adjustment of angle between two arms of the device. single or double level osteotomy is possible.
Multidirectional devices
essential component of these devices are angulation joints and two geared rods of variable lengths.
in bidirectional devices the middle joint is simple hinge whereas in multidirectional devices it is multifunctional double ball joint.
device can be adapted according to individual anatomic situations.
MD DOS Device ROD custom distractor device Buried bidirectional telescopic mandibular distractor Multiaxis intra oral distractor New spiral distractor Distractor with micro hydraulic cylinder
Posterior end of PFU is fixed in ascending ramus. Depth of PFU penetration is controlled by PFU screw length and bar spacer.
Anterior end of PFU is connected to posterior end of DU by hinge which allows DU to rotate along vertical axis. Anterior end of DU is connected to AFU which is basically a modified five hole plate.
Device fabrication
Distractor device consists of three components Anterior activated expander , male and female attachments. Male attachment is soldered to the crowns. Male attachment also have vertical slots for wire fixation.
Female part is soldered to expansion screw The intra oral attachment allows prefabrication of
The vector planning ROD lab. alignment tool was devolved to properly position the distractor bilat.
BTMD has mediolateral offset with an adjustable screw allowing intraoperative adjustment of distractor vector and postop correction of midline occlusal discrepancies.
BTMD is stainless steel device that can be attached to mandible with upto 1.9 to 2.3 mm monocortical or bicortical screws Activation is done by transmucosal approach. BTMD has also shown its use in mandibular defect reconstruction.
Spiral Distractor
Several authors suggest that mandible grows in archival fashion which has been hypothesized to be along logarithmic spiral. Based on this information semi buried distractor with curvilinear vector was devolved.
By placing the osteotomy and device at mandibular ramus the archival path of distraction would mimic the logarithmic spiral of mandibular growth.
Curvilinear vector is chosen by VTO
Both piston and cylinder have integrated fixation plates with two holes for bone fixation using conventional 3.5 mm bicortical screws Depending on situation both incremental and continuous distraction can be applied
Nonsyndromic mandibular hypoplasia associated with a dental malocclusion where movement of mandible required is >10mm Mandibular transverse deficiency associated with a dental malocclusion and dental crowding Severe obstructive sleep apnea in patients who are morbidly obese Shortened vertical height of the alveolar bone to receive an implant
Caution must be exercised in patients who have undergone radiation therapy. This is because of delayed bone formation due to reduced number of stem cells
Caution must be exercised in elderly patients because of the decreased number of mesenchymal stem cells
Treatment planning History Records Patient expectations Distraction device selection Predistraction, intradistraction and postdistraction treatment objectives Determination of vector Distraction protocol
Disadvantages : skin scarring poor patient compliance Intaoral devices Advantages : no scarring better patient compliance
Disadvantages :
difficult to place risk of injuries to nerves, vessels and tooth buds second surgical procedure is required for removal
desired lengthening Lengthening capabilities desired angular correction vector psychological requirements of patients
Lengthening capabilities
To achieve desired amount of lengthening and angular correction appropriate length of distractor must be selected.
Ratio of amount of device activation and observed amount of distraction can go as high as 2:1
Incorporation of angular correction further decreases total amount of linear distraction
Direction of distraction
Based on type of deformity and main goal of positional changes. If only ramus or body lengthening is required unidirectional distractor would be utilized.
If simultaneous ramus and body lengthening is required, distractor may be placed according to the following formula:
Pin placement angle = 180 gonial angle x ramus def / total def Pin placement angle = angle between vector of distraction and mandibular plane
Amount of Distraction: The amount of distraction can be determined by simply drawing a triangle two sides of which represents the amount of mandibular corpus and ramus shortening respectively. The angle between these two sides is the gonial angle and third side indicates amount of distraction. This can be calculated by using the formula:
Distraction amount = Dc + Dr 2 (Dc x Dr) x Cos a Dc = Corpus deficiency Dr = Ramus deficiency A = Gonial angle
Amount of distraction
In case of simultaneous maxillary defficiency amount of maxillary correction is also included in calculation. If deformity correction requires mandibular lengthening in combination with gonial angle change or transverse change, multidirectional distractor is required.
Bone ends should be separated by 10 mm before starting angular correction. Double level osteotomy can be performed in difficult cases.
Orthodontics
Predistraction orthodontics Intradistraction orthodontics Postdistracrtion orthodontics
VECTOR PLANNING
The distraction vector defines the desired direction that the distal segment must move during lengthening.
Despite precise planning the actual distal segment movement is difficult to predict and is affected by various forces:
osteotomy design osteotomy location distracton device orientation masticatory muscle influence occlusal interferences distraction device adjustment orthodontically applied forces
Mandible is V shaped when viewed in transverse plane, anatomic axis of right and left sides of mandible are not parallel to each other or to desired direction of distraction.
When viewed in sagittal plane, the inferior border of mandible is often not parallel to maxillary occlusal plane which is primary plane of reference for ant. mandibular distraction.
If distraction was placed parallel to the inferior border of the mandible, elongation occurred horizontally with opening or obliteration of gonial angle.
If distraction was placed obliquely to both ramus and body, neomandible maintained original form with preservation of gonial angle.
Laskin suggests planning distractor placement preoperatively to achieve desired results. Distractors placed parallel to the mandible with out regard to desired direction of distraction create reactive forces leading to following clinical problems:
bending of distractor device loosening of fixation screws bone resorption joint compression
The magnitude of lateral displacement tendency is proportional to amount of mandibular lengthening and mandibular arch angle.
Placement of distractor parallel to direction of distraction eliminates the tendency of lateral displacement of proximal segment.
If the distraction cannot be placed parallel to direction of distraction and lateral displacement tendency cannot be corrected they should be compensated either by acute correction or gradually incorporating a hinge element to lengthening device.
The vertical relationship between the distal mandibular segment and maxilla during distraction is another important consideration.
An increase in lower anterior facial height occurs when the vector of distraction is oriented parallel to mandibular plane instead to the maxillary ccclusal plane.
Vertical increase in lower anterior facial height may manifest as development of anterior /posterior open bite.
Increase in angle between occlusal plane vector = increased vertical deviation desired ( open bite )
and from
To prevent the development of open bite distractor should be placed as possible to desired direction of distraction, usually maxillary occlusal plane.
But open bite can still develop due to extrinsic and intrinsic factors. Extrinsic factors: rigidity of distractor stability of screws Intrinsic factors: soft tissue tension bone quality anatomy of mandible
Future growth and overcorrection Skeletal age and future growth potential must be considered for distraction planning
The amount of distraction required is based on careful assessment of mandible followed by compensation by growth standards or norms for particular race, sex, and facial skeleton maturity.
Surgical Therapy..
The orthodontist and the surgeon must have open communication throughout the entire planning process They must share the same treatment objectives
Superior to angle of mandible on ramus Deficient in body length Anterior to angle of mandible Combination of both? Anterior and/or superior to angle of mandible?
Vertical plane
Osteotomy / Corticotomty
corticotomy
circumferential
external
External extended
Depending on number
Single
Double
Widening
Midline
Alveolar
Horizontal segmental
corticotomy
Distraction
osteotomy
Distraction protocol
To start with
External extended Preserves vascularity and tooth buds Cancellous bone is spared 6-8 mm of inner cortical bone remains intact
Ramus osteotomy Vertical, downward and inward ramus distraction Required in hemifacial microsomia and other syndrome cases
Angular osteotomy
Ridge corticotomy is done in oblique and anterior direction and than sharply turned posterior to angle of mandible.
Device is placed, marked and removed.
Corpus osteotomy Horizontal and forward lengthening Inferior border channel retractor is placed between 2nd and 3rd molar. Mandible is than transected through both buccal and lingual cortex at inferior border, vertically upto 3mm of inferior alveolar canal Outer cortex is than sectioned
Protecting the lingual periosteum saw is placed upside down and osteotomy is carried through alveolar crest, sup. Inf. to 3mm superior to canal. 6 mm medial bone is kept intact
Device is placed
Closure is done with small aperture at the top of incision to facilitate vertically placed chisel , which is placed to give final cut followed by complete closure
Mandibular widening
Complete osteotomy is done midline between central incisors below the roots of incisors. Alveolar bone is than sectioned with bur taking care of teeth and gingiva
If teeth are very close the alveolar bone and gingiva,lingual cortex is green fractured with expansion forceps device.
Postoperative details
What should the surgeon watch for after the placement of distractor ? During the distraction phase, the patient should be seen every 2-3 days to monitor the advancement and to intercept any potential occlusal discrepancies During the consolidation phase, the patient should be seen on a weekly basis to monitor healing and ossification of the regenerate
COMPLICATIONS A complication is an unexpected deviation from the treatment plan that, with out appropriate correction will lead to worsening of existing, development of a new, or recurrence of the initial pathologic process
Mistake Mistake is an inattentive action that results in a deviation of the course of treatment, thereby leading to the development of a complication
Potential mistakes
Iatrogenic
Patient related
Potential complications
Axial deviation
Axial deviation of distracted segment can result from various mistakes. -inappropriate size and strength of device -inadequate osteotomy level -inadequate device orientation -inadequate hinge placement -inaccurate placement of device -comminuted osteotomy
Correction of axial deviation begins with elimination of main cause of this deviation. -replacement of distracter device -repositioning hinge axis -reorientation -additional surgery
Soft tissue overstretching Blood vessels rare least tolerant to compressive forces lead to ischemia
Adjacent joints degenerative changes Skin scaring and necrosis Infection incidence is 5-30%, more with extra oral devices
Distraction vs Osteotomy
Distraction Need for bone grafting Osteotomy Not necessary even for Necessary for defects defects > 20 mm >10 mm
3 Dimensional
Can be done
2 Dimensional
Think about permanent teeth and sufficiency of bone Risk of causing Risk of causing Not Possible Relatively inexpensive
Distortion and loading of the TMJ Damage to the inferior alveolar nerve Cost
Time
Takes time
Distraction osteogenesis is a highly predictable and reliable method of increasing the bone in a deficient mandible
With technology advancements, the distraction devices become smaller and more sophisticated making distraction movements more precise
One of the current controversies involves using distraction osteogenesis instead of the traditional bilateral sagittal split osteotomy Some authors have gone so far as to state that the bilateral sagittal split osteotomy is an obsolete procedure with no place in current practice
In reality, traditional mandibular osteotomies will always have a place; however, distraction osteogenesis provides the surgeon with another option in treating a wide variety of mandibular deficiencies
References
1.
Craniofacial distraction osteogenesis Mikhail L. Samchukov, Jason B. Cope, Alexander M. Cherkashin Distraction of the craniofacial skeleton Joseph G. McCarthy. Oral and maxillofacial Wardbooth. surgery Peter
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