Craniofacial Distraction, A Review

Int. J. Oral Maxillofac. Surg.
2001; 30: 89103

doi:10.1054/ijom.2000.0033, available online at http://www.idealibrary.com on
Invited review
Craniofacial distraction
osteogenesis: a review of the
literature. Part 1: clinical
studies
G. Swennen, H. Schliephake, R. Dempf, H. Schierle, C. Malevez: Craniofacial
distraction osteogenesis: a review of the literature. Int. J. Oral Maxillofac. Surg.
2001; 30: 89103. 2001 International Association of Oral and Maxillofacial
Surgeons
Abstract. A review of the literature dealing with distraction osteogenesis (DO) of
the craniofacial skeleton, provided by a PUBMED search (National Library of
Medicine, NCBI; revised 3 April 2000) from 1966 to December 1999 was
conducted. Key words used in the search were distraction, lengthening, mandible,
mandibular, maxilla, maxillary, midface, midfacial, monobloc, cranial, craniofacial
and maxillofacial. This search revealed 285 articles. One hundred and nine articles
were clinically orientated and were analysed in detail in this study. The type of
distraction, indications, age, type of surgery, distraction rates and rhythms, latency
and contention periods, amount of lengthening, follow-up period, relapse,
complications and the nature of the distraction device were analysed. This review
revealed that 828 patients underwent DO of the craniofacial skeleton; 579
underwent mandibular DO, 129 maxillary DO, 24 simultaneous mandibular and
maxillary DO and 96 midfacial and/or cranial DO. Craniofacial DO has proven to
be a major advance for the treatment of numerous congenital and acquired
craniofacial deformities. Treatment protocols and success criteria for craniofacial
DO are suggested on the basis of these results. There is still, however, a lack of
suicient data, especially on follow-up and relapse, so that treatment strategies
have to be validated by long-term studies in the future.
Gwen Swennen
1,2
,
Henning Schliephake
1
,
Rupert Dempf
1
, Hannes Schierle
1,3
,
Chantal Malevez
2
1
Department of Oral and Maxillofacial Surgery,
Medizinische Hochschule Hannover,
Hannover, Germany
2
Department of Oral and Maxillofacial Surgery,
Childrens Hospital, University of Brussels,
Belgium
3
Private Practice for Oral and Maxillofacial
Surgery, Karlsruhe, Germany
Key words: distraction; mandible; maxilla;
midface; cranial; treatment protocols; success
criteria.
Accepted for publication 20 November 2000
Distraction osteogenesis (DO) is the pro-
cess of generating new bone in a gap
between two bone segments in response
to the application of graduated tensile
stress across the bone gap. The tech-
nique of bone lengthening by DO was
rst described in 1905 by Coniviii:
13
,
when he reported lengthening of a
femur by axial distraction forces. Other
reports
1,2
also mention the concept of
bone lengthening in the tibia, but it
remained undeveloped until Dr Gavriel
A. Iiiz:ov
5456
, a Russian physician,
further developed the technique in the
1950s in Kurgan in West Siberia. For
more than 35 years he successfully
applied the technique of DO to the
enchondral bone of the upper and lower
extremities. A unique feature of the
distraction technique is that bone regen-
eration by DO is accompanied by simul-
taneous expansion of the functional soft
tissue matrix, including blood vessels,
nerves, muscles, skin, mucosa, fascia,
ligaments, cartilage and periosteum.
These adaptive changes of the surround-
ing soft tissues through the tension that
is generated by the distraction forces
applied on the bone, is called distraction
histogenesis
22
. Distraction osteogenesis
seemed to be a promising new method in
the reconstruction of the membranous
bones of the human craniofacial skel-
eton, when in 1992 McC:1nx et al.
83
reported the rst clinical application in
the Western literature of mandibular
lengthening by gradual distraction in
patients with hemifacial microsomia and
Nagers syndrome. Since then there has
been an explosion of reports in the lit-
erature on DO in the craniofacial skel-
eton. In recent years, DO has become
0901-5027/01/020089+15 $35.00/0 2001 International Association of Oral and Maxillofacial Surgeons
increasingly popular and opened new
therapeutic perspectives for the treat-
ment of numerous congenital and
acquired craniofacial skeletal anomalies.
Dierent treatment protocols, however,
are applied by dierent groups. Despite
the growing body of literature on the
applications of craniofacial DO, import-
ant parameters such as age, rhythm,
rate, latency period, contention period
are not rigidly established. Excellent
comprehensive reviews have been pub-
lished
4,22,24,82,133,134,137,145
, however,
none of these provide an analysis of
these parameters in detail. Therefore, the
literature dealing with DO of the cranio-
facial skeleton was reviewed comprehen-
sively. The purpose of this review was
two-fold: (1) to evaluate clinical indi-
cations and DO parameters by compar-
ing dierent treatment protocols and
results obtained by dierent craniofacial
teams; (2) to suggest treatment protocols
and success criteria for craniofacial DO
based on clinical, experimental and
scientic investigations to help provide
more objective data in the future.
Materials and methods
A review of the literature on DO of the
craniofacial skeleton, provided by a
PUBMED search (National Library of
medicine, NCBI, New Pubmed System;
revised 3 april 2000), was conducted
from 1966 to December 1999. Key words
applied in the search were distraction,
lengthening, mandible, mandibular,
maxilla, maxillary, midface, midfacial,
monobloc, cranial, craniofacial and
maxillofacial. This initial search revealed
285 articles. An additional three articles
relating to the subject were submitted to
the study. Of this total study sample of
288 articles, 109 were clinical and 99
were experimental articles; 54 articles
were primarily on a scientic basis and
were excluded because they provided no
suicient data; of the remaining articles,
11 were excluded due to lack of appro-
priate data and 15 because they were
written in languages, for which trans-
lation was not available (12 in Russian,
two in Chinese and one in Hebrew)
(Table 1). The study sample of this
review consisted of 109 articles that were
analysed in detail. Flow sheets were
made of each article with the specic
parameters relative to DO. The author,
type of distraction, indications, number
of patients, age, type of surgery, distrac-
tion rates and rhythms, latency and con-
tention periods, amount of lengthening,
follow-up period, relapse, complications
and the nature of the device were
recorded for each article on the ow
sheets and analysed. The articles were
divided into four major groups accord-
ing to the site of distraction: mandible,
maxilla, combined mandible and max-
illa, and midface/cranium. Although
some authors have published results of
identical patients in more publications,
this could not be veried in detail.
For analysis, the data of all dierent
publications were used.
Results
A total of 109 articles were analysed; 74
(67.9%) were related to mandibular DO,
16 to maxillary DO (14.7%), three to
simultaneous mandibular/maxillary DO
(2.8%) and 23 to midfacial and/or
cranial DO (21.1%); seven of these
articles were related to two or more
procedures (Table 2). Indications for
craniofacial DO are shown in Table 3.
Mandibular distraction osteogenesis
A total of 579 patients (70.0%) under-
went distraction procedures involving
the mandible (Table 3). These mandibu-
lar DO procedures were divided into
four groups. Of the 579 patients, 430
(74.3%) underwent mandibular length-
ening (Group 1), 38 patients (6.6%)
mandibular widening (Group 2), 16
patients (2.8%) alveolar reconstruction
(Group 3) and 95 patients (16.4%) bone
transport and compression DO (Group
4). Results of mandibular DO par-
ameters for each group are shown in
Table 4.
Group 1: Mandibular lengthening
Of the 430 patients that underwent
mandibular lengthening through DO,
345 (80.2%) had congenital micro-
gnathia
8,11,14,16,19,2331,42,45,46,51,52,53,57,
59,62,63,6567,72,73,79,8385,87,88,94,98,101,102,
105,107,108,115,120,123,126,130,135,141,144
45
(10.5%) had acquired micro-
gnathia
8,25,29,30,31,36,59,6264,66,84,88,91,98,
108,119,130,141,147
and 40 (9.3%) had man-
dibular retrognathia
26,31,91
. Detailed
data regarding age were available in 156
patients (45.2%) with congenital micro-
gnathia and in 26 patients (57.8%) with
acquired micrognathia. In the congenital
micrognathia sample, age varied from 6
days to 19 years and most of the patients
were distracted in the age groups, 26
and 712 years. Patients with acquired
micrognathia were distracted at an age
varying from 1.5 to 64 years with most
of the patients distracted in the 712
years age group. Data regarding age
were available in 37 patients (92.5%)
with mandibular retrognathia; all
patients were distracted between the age
of 15 and 20 years. A total of 289
patients (83.8%) with congenital micro-
gnathia, 40 patients (88.9%) with
acquired micrognathia and 40 patients
(100%) with retrognathia had infor-
mation regarding the surgical technique.
A complete osteotomy was performed in
166 patients (57.4%) with congenital
micrognathia, while 123 (42.6%) under-
went a corticotomy. In the acquired
micrognathia sample a total of 23
patients (56.1%) underwent an osteo-
tomy, while 18 patients (43.9%) a
corticotomy. A body osteotomy was per-
formed in all patients with mandibular
retrognathia. Data regarding the distrac-
tion rate were available in 300 patients
(86.9%) with congenital micrognathia,
37 (82.2%) with acquired micrognathia
and 40 (100%) with mandibular retrog-
nathia. The distraction rate of 1 mm
daily was the most frequent for each
group. Data on distraction rhythm,
varying from two to four times daily,
were reported in only 174 patients (58%)
in the congenital micrognathia sample
and in 10 patients (27%) in the acquired
micrognathia sample. All patients in the
retrognathia sample had data on distrac-
tion rhythm, ranging from three times
0.33 mm to twice 0.5 mm. A total of 325
Table 1. Articles on distraction osteogenesis
of the craniofacial skeleton
Clinical DO 109
Experimental DO 99
Scientic DO 54
Not relevant 11
Other language 15
Total 288
Table 2. Articles on clinical distraction osteogenesis
Mandibular DO 74 74
Maxillary DO 16 4* 12
Simultaneous mandibular/maxillary DO 3 3
Midfacial and/or cranial DO 23 3** 20
Total 109
*Of the 16 articles on maxillary DO, four concerned also mandibular DO.
**Of the 23 articles on midfacial and/or cranial DO, three concerned also mandibular DO.
90 Swennen et al.
Table 3. Indications for distraction osteogenesis of the craniofacial skeleton
Number % %
Mandibular DO
Hemifacial microsomia (HFM)
28,29,30,31,46,53,59,67,73,65,66,79,83,87,88,101,102,105,123,126,130,135
198 34.2
Segmental bone defect (trauma, tumor)
6,9,76,113,116118,121,122
90 15.5
Class II
26,31,91
40 6.9
Acquired micrognathia (trauma, TMJ ankylosis)
8,25,29,30,31,59,64,65,66,85,88,97,98,108,141
39 6.7
Transverse discrepancy
41,60,142,143
35 6.0
Craniofacial microsomia (CFM)
11,13,14,84,85,98,108,130
32 5.5
Treacher-Collins Syndrome (TC)
8,29,72,65,66,87,88,94,98,108,144
27 4.7
Congenital micrognathia
8,42,45,51,59,84,87,98,105
24 4.1
Obstructive Sleep Apnoe Syndrome (OSAS)
16,52,91
18 3.1
Alveolar deciency
37,38,47,69,139
16 2.8
Nager Syndrome
59,79,83,87,108,115,144
10 1.7
Pierre Robin Syndrome
8,57,58,88,107,120
8 1.4
Goldenhar Syndrome
8,11,87,98,108
6 1.0
Fibula
36,119,147
6 1.0
Arthrogryposis
11,98
3 0.5
Hypoglossia-hypodactyly Syndrome
8,99
2 0.4
Hanhart Syndrome
29,73
2 0.4
Post irradiation therapy
8
2 0.4
Condylar resorbtion
124
2 0.4
Moebius Syndrome
62,63
2 0.4
Histiocytose X
121,122
2 0.4
Rubinstein-Taybi Syndrome
79
1 0.2
Cerebro Costo mandibular Syndrome
79
1
Tessier cleft VII
65
1
Retrognathia/facial cleft
65
1
Plagiocephaly
23
1
Kampomele dysplasie
115
1
Trisomie 18
115
1
Morpheaform sleroderma
23
1
Amnionband Syndrome
8
1
Neurobromatosis
8
1
Glossoptosis-micrognathia
107
1
Aglossia-micrognathia
8
1
Silver-Russell Syndrome
61
1
Facial skoliosis
58
1
Bilateral dysostosis mandibularis
141
1
Subtotal 579 100 70.0
Maxillary DO
Orofacial clefts 115 89.2
Unilateral cleft lip-palate (UCLP)
3,34,70,89,106,127,128,141
55
Bilateral cleft lip-palate (BLCP)
34,70,89,103,106,127,128,132,146
34
Undened clefts
104
18
Unilateral cleft palate (UCP)
70,89
8
Alveolar defect
37
5 3.9
Nasomaxillary Dysplasia
89
2 1.6
Prognathism
89
2 1.6
Alveolar atrophy
37,47
2 1.6
Cleidocranial Dysostosis
19
1 0.8
Craniosynostosis (CST)
70
1 0.8
Oral-acral syndrome
32
1 0.8
Subtotal 129 100 15.6
Simultaneous mandibular/maxillary DO
HFM
90,95,96
23 95.8
TC
96
1 4.2
Subtotal 24 100 2.9
Midfacial and/or cranial DO
Craniosynostosis (CST) 86 90.0
Crouzons S
5,10,12,19,20,21,27,68,125
36
Aperts S
5,10,12,18,19,20,27,77
19
Undened Craniosynostosis
77,81
15
Pfeiers S
7,10,11,12,17,18,19,21,100
12
Unilateral Coronal Synostosis
71
1
Bilateral Coronal Synostosis
49
1
Sagittal Synostosis
125
1
Carpenters S
131
1
Midfacial cleft
10,12
3 3.1
UCLP
15,19
3 3.1
Unilateral CFM
14,19
2 2.1
BCLP/severe maxillary atrophy
48
1 1.0
Rare cleft
19
1 1.0
Subtotal 96 100 11.6
Total 828 100
Craniofacial distraction 91
patients (94.2%) in the congenital micro-
gnathia sample, 40 (88.9%) in the
acquired micrognathia sample and 35
(88.9%) in the retrognathia sample had
data on the latency period. The 57 day
latency period was the most common in
each group. Data regarding the conten-
tion period were reported in 287 patients
(83.2%) with congenital micrognathia, in
35 patients (77.8%) with acquired micro-
gnathia and in 40 patients (100%) with
retrognathia. The 68 week contention
period was found to be the most fre-
quent in all groups. In the age groups
712 and 1316, however, the 23 month
contention period was more common
than the 68 week contention period. All
patients in this group had data on the
distraction device. In the congenital
micrognathia sample, a total of 283
patients had external distraction devices:
227 (80.2%) were monodirectional, 44
(15.6%) bidirectional and 12 (4.2%)
multidirectional devices. A total of 62
patients (18.0%) in this sample had inter-
nal devices; 61 of them had information
on the type of device and were all mono-
directional. In the acquired micro-
gnathia sample, there were 14 patients
(31.1%) who had internal monodirec-
tional devices and 31 patients who had
external devices; 16 were monodirec-
tional, 12 bidirectional, two multidirec-
tional and one unknown. All patients
with mandibular retrognathia had inter-
nal devices; 35 were bone-borne and ve
were tooth-borne. A total of 318 patients
(92.2%) with congenital micrognathia
had data on the amount of lengthening,
varying from 1 to 95 mm; in 305 patients
(96.0%) a distraction distance was ob-
tained of more than 10 mm. In the ac-
quired micrognathia sample, 37 patients
(82.2%) had data regarding the amount
of lengthening varying from three to
36 mm; 34 patients (91.9%) were dis-
tracted for more than 10 mm. All
patients with mandibular retrognathia
had data on the obtained distraction dis-
tance, varying from 6.8 to 28 mm. In the
congenital micrognathia sample, data
on follow-up (varying from 1 month to
7 years) and relapse were reported in
237 (68.7%) and 152 patients (44.1%),
Table 4. Mandibular DO: DO parameters related to indication
Mandibular lengthening
Transveral
discrepancy
Alveolar
deciency
Bone
transport Total %
Congenital
micrognathia
Acquired
micrognathia Class II
Age
<2 y 17 1 18 6.8
26 y 70 (44.9%) 6 1 77 29.1
712 y 53 (40%) 10 (38.5%) 3 2 68 25.7
1316 y 13 5 9 27 10.2
>16 y 3 4 14 15 (100%) 39 (95.1%) 75 28.3
156 26 27 15 41 265 100
Surgical technique
Body corticotomy 1 2 3 0.6
Ramus corticotomy 2 2 0.4
Angle corticotomy 120 16 136 28.7
Body osteotomy 9 7 40 (100%) 43 99 20.9
Ramus osteotomy 64 9 73 15.4
Angle osteotomy 93 7 1 101 21.3
Midline osteotomy 38 (100%) 38 8.0
Segmental osteotomy 16 (100%) 16 3.4
Reverse-L osteotomy 6 6 1.3
289 41* 40 38 16 50 474 100
Distraction rate
1 mm/d 281 (93.7%) 33 (89.2%) 40 (100%) 12 10 (62.5%) 50 (100%) 426 88.6
>1 mm/d 11 11 2.3
<1 mm/d 8 4 26 (68.4%) 6 44 9.2
300 37 40 38 16 50 481 100
Latency period
<3 d 16 4 1 21 4.2
35 d 71 7 3 9 1 5 96 19.3
57 d 227 (70.0%) 25 (62.5%) 32 (91.4%) 28 (73.7%) 15 (93.8%) 2 329 66.1
>7 d 11 4 37 52 10.4
325 40 35 38 16 44 498 100
Contention period
<2 w 2 1 1 4 1.0
23 w 24 3 27 6.8
45 w 16 10 (3)** 2 28 7.1
68 w 210 (73.2%) 18 (51.4%) 37 (92.5%) 13 (59.1%) 7*** (43.8%) 285 71.8
23 m 34 3 9 0 46 11.6
46 m 1 6 7 1.8
287 35 37 (40) 22 16 397 100
Devices
I 62 14 40 (100%) 36 (94.7%) 16 (100%) 168 31.5
E 283 (82.0%) 31 (68.9%) 2 50 (100%) 366 68.5
345 45 40 38 16 50 534 100
*In one patient a body and ramus osteotomy was performed; **three patients had a 34 week contention period; ***all seven patients had a
contention period of 8 weeks.
Distraction implant that will be used for prosthetic treatment after the contention period.
92 Swennen et al.
respectively; only 62 patients (26.2%)
were followed-up for 1 year or longer and
only six relapses (4.0%) were reported. A
total of 26 patients (57.8%) in the ac-
quired micrognathia sample had data on
follow-up varying from 3 months to 4
years; only nine patients (34.6%) were
followed-up for 1 year or longer. Data on
relapse were only available in 10 patients
(22.2%); none of these patients showed
skeletal relapse. No data regarding
follow-up and relapse were reported in
the mandibular retrognathia sample.
Data on complications were available for
311 patients (72.3%); a total of 86 compli-
cations were reported (Table 5).
Based on these results, the common
standard appears to be a distraction
rate of 1 mm daily, a latency period of 57
days and a contention period of 68
weeks for patients with congenital or ac-
quired micrognathia and retrognathia
undergoing mandibular lengthening. In
patients with congenital or acquired
micrognathia, both surgical techniques
(complete osteotomy/corticotomy) can be
performed and both devices (external or
internal) can be applied. In retrognatic
patients a complete osteotomy of the
mandibular body and bone-borne inter-
nal devices are recommended (Table 6).
Group 2: Mandibular widening
A total of 38 patients underwent sym-
physeal widening through DO
41,60,61,98,
99,142,143
. Detailed information on age
was given in 27 patients (71.1%); nine
patients (33.3%) were distracted between
13 and 16 years, 14 patients (51.9%)
older than 16 years and four patients
(14.8%) younger than 13 years. Further-
more, mandibular widening was
reported in 10 patients with unspecied
age between 13 and 31 years
41
. Thus, a
total of 33 patients (89.2%) were dis-
tracted at an age older than 12 years and
only four patients (10.1%) at an age
between 212 years. Three of these four
patients were syndromic cases. In all
patients a midline osteotomy was per-
formed. A total of 12 patients were dis-
tracted at 1 mm daily, while 26 were
distracted at less than 1 mm daily; 24
were distracted at 0.75 mm daily (three
times 0.25 mm), one at 0.5 mm and
another at 0.33 mm. Latency periods
were reported in all patients. The 57
day latency period was the most com-
mon. Data regarding the contention
period were given in 22 patients (57.8%).
The 68 weeks contention period was
reported most frequently. A total of 23
patients (60.5%) had data on the amount
of symphyseal widening varying from
3.9 to 14 mm. Only 16 patients (42.1%)
had follow-up data varying from 6 to
45 months and none of all patients had
information on relapse. Of the 38
patients that underwent mandibular
widening through DO, two (5.3%) had
external devices and 36 (94.7%) inter-
nal monodirectional devices; 33 were
tooth-borne and three bone-borne
devices. Data on complications were
reported in 37 patients (97.4%); a total
of 10 complications (29.7%) occurred
(Table 5).
Thus, it is recommended to perform
mandibular widening from the age of 12
years after a complete symphyseal
osteotomy using an internal device, a
distraction rate ranging from 0.75 to
1 mm daily, a 57 day latency period and
a 68 weeks contention period (Table 6).
Group 3: Alveolar reconstruction
In this group 16 patients underwent
alveolar reconstruction through vertical
DO
11,37,38,47,69,139
. Data regarding age
were available in 15 patients (93.8%) and
varied from 17 to 69 years. A segmental
osteotomy was performed in all patients.
A total of 10 patients had a distraction
rate of 1 mm, while six had a rate of
0.5 mm. Data regarding distraction
rhythm were available for only nine
patients (56.3%); eight patients had a
rhythm of 0.5 mm twice a day while one
0.5 mm once daily. The 57 days latency
period and the 8 week contention period
were the most common. In group 3 all
devices that were used were intraoral
devices; nine patients (56.3%) had inter-
nal monodirectional devices and seven
patients (43.8%) had implant-borne
Table 5. Complications of distraction osteogenesis of the craniofacial skeleton
Distraction procedure
Total % Length
Mandibular
Bone T
Maxill.
adv/alv
Mand/
maxill.
Midf/
cranial Widen. Alveol.
Complications
Mech. problems (pin loosening/accidental trauma) 34 1 1 1* 7 44 33.1
Transient hypesthesia inferior alveolar nerve 15 15 11.3
Minor local infection 5 4 1 2 12 9.0
Pin infection 5 1 1 4 11 8.3
Premature consolidation 5 4 1 10 7.6
Transient weakness r.marginalis facial nerve 9 9 6.7
Limited skeletal advancement 6 6 4.6
Hypertrophic scar 4 4 3.0
Asymmetric advancement 3 3 2.3
Ankylosis (zygoma-coronoid processus) 3 3 2.3
Severe infection 3** 3 2.3
Tooth damage 1 2 3 2.3
Tooth mobility 2 2 1.5
Incomplete osteotomy 2 2 1.5
Loss of distraction implant 1 1 2 1.5
Incorrect distraction vector 1 1 0.8
Pseudarthrosis 1 1 0.8
Haematoma 1 1 0.8
Periodontal pocket 1 1 0.8
86 10 1 7 3 1 25 133 100
*Loosening of IMF; **2 meningitis, 1 H.u.pneumonia.
devices; six of these were used for pros-
thetic treatment after distraction was
completed
37,38
, while one was removed
at the end of the activation period
69
.
Data on the amount of lengthening were
reported in 15 patients (93.8%) and varied
from 4 to 15 mm. Internal bone-borne
devices provided greater lengthening
(715 mm) compared to implant-borne
devices (48 mm). Follow-up was men-
tioned in 14 cases (87.5%) and ranged
from 1 to 13 months. None of these ar-
ticles provided data on skeletal relapse.
Data on complications were only avail-
able in six patients; only one complication
occurred (Table 5).
It can be recommended to perform
mandibular alveolar reconstruction from
the age of 16 years after a segmental
osteotomy using a distraction rate of
1 mm daily, a latency period of 57 days
and a contention period of 8 weeks with
an internal bone-borne device. A 0.5 mm
rate and a 46 months contention period
is recommended when a distraction
implant is used, that will serve for pros-
thetic treatment after the contention
period (Table 6).
Group 4: Bone transport
Bone transport DO was performed in a
total of 50 patients. Six patients (12%)
underwent bifocal bone transport DO
for reconstruction of a neocondyle (TMJ
sample)
9,121,122,124
, while 42 patients
(84%) underwent bifocal bone trans-
port
6,9,76,117,118
and 2 patients (4%) tri-
focal bone transport
76,113
DO for
reconstruction of segmental defects due
to trauma or tumor resection. A total of
45 patients underwent reconstruction of
segmental defects through compression
DO
116118
. Detailed data on age were
reported in 41 patients (82%) who
underwent bone transport DO. A total
of 39 patients (95.1%) were distracted
above the age of 16 years, varying from
20 to 68 years. Data on age were only
available in seven of the patients (15.6%)
who underwent compression DO; they
all were distracted at an age varying
from 20 to 35 years. A reverse-L oste-
otomy was performed in all six patients
who had TMJ reconstruction, while an
osteotomy of the mandibular body was
made in 88 patients (98.9%), who had
reconstruction of segmental defects by
bifocal, trifocal or compression DO. All
patients in this group had a distraction
rate of 1 mm daily. In the TMJ sample,
ve patients had a distraction rhythm of
twice a day, and one patient once a day.
In 84 (94.4%) of the 89 patients who
underwent segmental bone reconstruc-
tion through bifocal, trifocal bone trans-
port DO or compression DO, distraction
rhythms varying 24 times a day were
used. Data regarding the latency period
were reported in 43 patients (97.7%) who
had bifocal or trifocal bone transport
DO for reconstruction of segmental
defects; 37 patients (88.3%) had a
latency of 1012 days. Only one patient
in the TMJ sample had information on
the latency period, which was 5 days. All
patients who underwent compression
DO had a latency period of 1012 days.
Data regarding the contention period
were available in 43 patients (97.7%),
who underwent segmental bone recon-
struction through bifocal or trifocal DO;
4 weeks, 1.52.5 months and 3 months
contention periods were reported in 5
(11.6%), 37 (86.1%) and 1 (2.3%) patient,
respectively. A total of 33 patients
(73.3%) in the compression DO series
had a 12 months contention period,
while 12 (26.7%) had one of 1.52.5
months. In the TMJ sample, data were
only available in three patients; they all
had a contention period of 56 weeks. In
the TMJ sample, all patients had exter-
nal devices; ve had monodirectional
devices and one had a bidirectional
device. All patients who underwent seg-
mental bone reconstruction through
bifocal and trifocal DO had external
devices, however only nine (20%) had
further information on the type of
device; four patients had monodirec-
tional, three bidirectional devices and
two multidirectional devices. In the com-
pression DO sample, all patients had
external devices but no information
regarding the type of the device was
reported. The amount of lengthening
was mentioned in all patients who
underwent segmental reconstruction by
Table 6. Treatment protocols for mandibular distraction osteogenesis
Type of surgery Rate Latency Contention Device
Mandibular lengthening
Mandibular micrognathia
<2*/26**/712***/>16 y**** Corticotomy 1/d 57 d 68 w E
I
Osteotomy 1/d 57 d 68 w E
I
Mandibular retrognathia
>14 y Body osteotomy 1/d 57 d 68 w I
Mandibular widening
>12 y Symphyseal osteotomy 0.751/d 57 d 68 w I
Mandibular alveolar reconstruction
>16 y Segmental osteotomy 1/d 57 d 8 w I
0.5/d 57 d 46 m I
Mandibular bone transport
TMJ reconstruction
>16 y Reverse-L osteotomy 1/d 57 d 56 w E
I
Segmental defect reconstruction
>16 y Body osteotomy 1/d 1012 d 68 w E
*DO can be performed in newborns with upper airway obstruction who are tracheostomy-dependent.
**Ideal age group to perform DO in patients with severe craniofacial anomalies.
***DO should only be performed in severe anomalies who hadnt prior surgery or eventually a secondary distraction in case of growth deciency
after a costochondral graft
86
.
****DO can be performed in cases with delayed treatment or residual postsurgical growth disturbance.
Physical therapy during the activation and contention period to induce functional remodeling for the creation of a neocondyl.
94 Swennen et al.
bifocal or trifocal DO varying from 12
to 98 mm and in all patients who had
compression DO, varying from 5 to
45 mm. Only two patients in the TMJ
sample had data available on the
amount of lengthening (17 and 18 mm).
In the TMJ sample data regarding
follow-up were available for three
patients (50%) ranging from 15 to 20
months. Only two patients in this group
had data regarding relapse; both had no
skeletal relapse. Only seven patients
(15.9%) in the bifocal and trifocal recon-
struction sample had follow-up data
ranging from 6 months to 4 years. No
data on relapse were reported in this
sample. None of the patients who under-
went compression DO had data on
follow-up or relapse. A total of 68
patients (76.4%) that underwent segmen-
tal reconstruction had data on compli-
cations; seven complications (10.3%)
occurred (Table 5). None of the patients
in the TMJ sample had information
regarding complications.
Based on these results it can be recom-
mended to perform TMJ reconstruction
from the age of 16 years after a reverse-L
osteotomy using a 1 mm distraction rate,
a 57 day latency period, a 56 week
contention period and an external
device; although internal devices can
also be used. For segmental bone recon-
struction a complete osteotomy of the
mandibular body can be performed from
the age of 16 years using a 1 mm distrac-
tion rate, a 1012 day latency period, a
68 week contention period and an
external device (Table 6).
Maxillary distraction osteogenesis
A total of 129 patients (15.6%) under-
went DO procedures involving the
maxilla; 122 patients (94.5%) underwent
maxillary advancement
3,19,34,70,89,103,
104,106,127,128,132,141,146
and seven
patients (5.4%) maxillary alveolar recon-
struction
37,47
. Results of maxillary DO
parameters are shown in Table 7.
Detailed data regarding age were
reported in 90 patients (73.8%) who
underwent maxillary advancement vary-
ing from 5 to 28 years. Most of the
patients were distracted in the 5 to 13
years age group. All seven patients
undergoing maxillary alveolar recon-
struction were distracted between 17 to
60 years of age. Detailed data regarding
the surgical technique were available in
127 patients (98.5%). In the age group of
513 years, 31 patients (44.3%) under-
went a complete and 39 patients (55.7%)
an incomplete Le Fort I osteotomy. The
complete Le Fort I osteotomy was the
most frequently performed procedure
in the other age groups. A segmental
osteotomy was performed in all patients
who underwent maxillary alveolar
reconstruction through DO. Two dier-
ent protocols were reported regarding
the distraction rate depending on the
distraction device in maxillary advance-
ment procedures. The rst group of 62
patients was distracted using a facial
mask applying continuing distraction
forces of 700900 g, while the other
group was distracted at 1 mm daily; 55
patients were distracted using a rigid
external distraction (RED) system and
six patients using a monodirectional
Table 7. Maxillary DO: DO parameters related to indication
UCLP BCLP Clefts
N-max.
Dyspl. Progn.
Cleid.
Synost.
Oral-
Acral S CST
Vertical
atrophy Total %
Age
513 y 39 18 8 2 2 1 1 1 72 74.2
1316 y 5 4 9 9.3
>16 y 4 5 7 16 16.5
97 100
Surgical technique
Le Fort I ost. (C) 32 23 19 1 1 76 59.8
Le Fort I ost. (I) 22 11 7 2 2 44 34.7
Segmental ost. 7 7 5.5
127 100
Distraction rate
1 mm/d 23 17 15 1 1 1 2 60 46.9
0.5 mm/d 5 5 3.9
700900 g 31 16 11 2 2 62 48.4
>1 mm/d 1 1 0.8
128 100
Latency period
3 d 6 3 9 7.0
35 d 13 7 1 1 22 17.2
45 d 35 23 25 2 2 1 88 68.8
57 d 1 1 7 9 7.0
128 100
Contention period
24 w* 26 18 15 1 60 48.8
23 m 28 16 7 2 2 1 2 58 47.2
46 m 5 5 4.1
123 100
Devices
Face mask 31 16 11 2 2 62 48.4
RED 22 17 15 1 55 43.0
I/mono 2 1 1 2 6 4.7
I/implant 5 5 3.9
128 100
RED: Rigid external distraction device/(C) Complete Le Fort I osteotomy: pterygomaxillary disjunction is performed/(I) Incomplete.
Le Fort I osteotomy: pterygomaxillary disjunction is not performed.
*Further contention with facial mask (48 weeks) or orthodontic elastics (2 months).
internal distraction device. One patient
underwent maxillary advancement by
DO using the RED system with a
distraction rate of more than 1 mm. In
the maxillary alveolar reconstruction
group, two patients were distracted at
1 mm daily (twice 0.5 mm) using an
internal monodirectional distraction
device and ve were distracted at 0.5 mm
daily through the use of a distraction
implant. The 45 day latency period was
the most frequent for maxillary advance-
ment DO, while all patients who under-
went alveolar reconstruction had one
of 57 days. Of the 122 patients that
underwent maxillary advancement, data
regarding the contention period were
reported in 116 patients (95.1%); 56
patients (48.3%) had a contention period
of 23 months and 60 patients (51.7%) a
contention period of 24 weeks. Of those
60 patients, however, maxillary DO was
performed in 54 using a rigid external
distraction device followed by night-time
retention with a facial mask during
48 weeks, while the other six patients
were distracted using a facial mask fol-
lowed by further orthodontic contention
with elastics for a period of 3 months. In
the alveolar reconstruction group, the
ve patients who were distracted with a
distraction implant, had a contention
period of 46 months, while the two
patients who were distracted with an in-
ternal monodirectional distraction device,
had a contention period of 23 months.
Data regarding the amount of maxillary
advancement were available in 121
patients (99.2%) varying from 1 to
17 mm; 50 patients (41.3%) had a distrac-
tion distance of more than 6 mm (36 had
a complete and 14 an incomplete Le Fort
I osteotomy). All patients who underwent
alveolar reconstruction had data on the
amount of lengthening varying from 3 to
15 mm; the bone-borne distraction de-
vices provided greater lengthening (7
15 mm) compared to the implant-borne
devices (35 mm). Follow-up data were
reported in 109 patients (84.5%) and
ranged from 3 months to 3 years, with 79
patients (61.2%) followed up for 6 months
or more. Data on relapse were reported
in 65 patients (50.4%); two had skeletal
relapse. In 87 patients (67.4%) informa-
tion regarding complications was given;
2 complications occurred (Table 5).
Thus, it appears recommendable to
perform maxillary advancement from
the age of 5 years after a complete Le
Fort I osteotomy using an internal or
external device, a 1 mm distraction rate,
a 45 days latency period and a 23
months contention period. In the 513
years age group, an incomplete Le Fort I
osteotomy can be performed and a facial
mask can be used for mild deformities
(Table 8). Recommendations concerning
the parameters for maxillary expansion
(Table 8) are based on the scientic
report of Moxx:r1s
93
, while those for
maxillary alveolar reconstruction are
the same as for mandibular alveolar
reconstruction (Table 5).
Simultaneous mandibular and maxillary
distraction osteotogenesis
In this group, 24 patients (2.9%) under-
went simultaneous mandibular and
maxillary DO
90,95,96
. Of the 24 distrac-
tion procedures, 23 (95.8%) were carried
out in HFM patients and one in a TC
patient. Data on age were available for
all patients and ranged from 11 to 32
years. All 24 patients had mandibular
distraction procedures with simul-
taneous maxillary DO through IMF.
Two dierent surgical techniques were
reported: 21 patients (all HFM) under-
went a unilateral mandibular ramus
corticotomy in combination with a com-
plete Le Fort I osteotomy at the aected
site and an incomplete Le Fort I oste-
otomy at the unaected site
90,95
; three
patients, two HFM and one TC, under-
went a unilateral and bilateral osteo-
tomy, respectively, of the mandibular
ramus combined with a bilateral com-
plete Le Fort I osteotomy
96
. All patients
had a distraction rate of 1 mm daily and
a latency period of 5 days. Contention
periods of 46, 7 and 810 weeks were
reported in eight (33.3%), one (4.2%)
and 15 patients (62.5%), respectively.
Distraction of the mandibular ramus
was performed in 21 patients (87.5%)
using an external monodirectional device
and in three patients (12.5%) using
an internal monodirectional device.
Data on mandibular lengthening were
reported in all patients varying from 12
to 28 mm, while only 21 patients had
data on the degree of maxillary rotation
varying from 12 to 18 degrees. Follow-
up was only reported in nine cases
(37.5%) and ranged from 4 to 25
months. Data regarding relapse were
only mentioned in two patients (8.3%),
showing no skeletal relapse. Information
on complications was reported in
Table 8. Treatment protocols for maxillary distraction osteogenesis
Maxillary advancement
513 y Incomplete Le Fort I 700/900 g 45 d 23 m Facial mask*
Complete Le Fort I 700/900 g 45 d 23 m Facial mask*
1/d 45 d 24 w** RED
1/d 45 d 23 m I
1316 y Complete Le Fort I 1/d 45 d 24 w** RED
1/d 45 d 23 m I
>16 y Complete Le Fort I 1/d 45 d 24 w** RED
1/d 45 d 23 m I
Maxillary expansion
>14 y Incomplete Le Fort I*** 0.33/d 57 d 36 m I/bone
0.251/d 57 d 36 m I/tooth
Maxillary alveolar reconstruction
>16 y Segmental osteotomy 1/d 57 d 2 m I
0.5/d 57 d 46 m I
Complete Le Fort I: pterygomaxillary disjunction is performed/Incomplete Le Fort I: the pterygomaxillary suture and septal base remain intact.
*A facial mask should only be used for mild deformities (anterior crossbite <7 mm).
**24 week contention with a rigid external distraction device, followed by 48 w night-time retention with a facial mask.
***The anterior (piriform aperture), lateral (zygomatic buttress) and median (midpalatal suture) bony supports of the maxilla are osteotomized;
septal release is only performed in cases of unilateral expansion.
96 Swennen et al.
only eight patients (33.3%); only one
complication occurred (Table 5).
This procedure can be performed
from the age of 12 years using a 1 mm
distraction rate, a 5 day latency period,
a 2 month contention period and an
external or internal mandibular device in
combination with IMF. We further sug-
gest that a mandibular device can be
combined with an internal maxillary
device, instead of IMF. Both surgical
procedures can be performed (Table 9).
Midfacial and/or cranial distraction
osteogenesis
A total of 96 patients (11.6%) underwent
DO procedures involving the midface
and/or cranium
5,7,1012,14,15,1721,27,48,49,
68,71,77,81,100,125,131,136
(Table 3). Results
of midfacial and/or cranial DO par-
ameters are shown in Table 10. Data on
age were reported in 88 patients and
varied from 3 months to 35 years; 32
patients were distracted at 47 years
while 28 patients underwent DO of the
midface and/or cranium under the age of
4 years; 19 of those were distracted
under the age of 1.5 years. A total of 62
patients (64.6%) had midfacial advance-
ments, while 25 had monobloc (MB)
advancements after a MB osteotomy.
Below the age of 4 years MB DO was the
most performed surgical technique in a
total of 19 patients (12 were below the
age of 1.5 years), while in the other age
groups the Le Fort III procedure was
the most frequent. Three patients
with Aperts Syndrome underwent com-
bined MB and facial bipartition (FB)
Table 9. Treatment protocols for simultaneous mandibular and maxillary distraction osteo-
genesis
>12 y Ramus corticotomy 1/d 5 d 2 m E/mono
Le Fort I osteotomy* IMF
Ramus osteotomy 1/d 5 d 2 m I/mono
Le Fort I osteotomy** IMF
*Complete Le Fort I osteotomy at the aected site, and incompleted Le Fort I osteotomy at the
unaected site.
**Complete Le Fort I osteotomy at both the aected and unaected site.
Table 10. Midfacial and/or cranial DO: DO parameters related to indication
Crouzons Aperts Pfeiers
Other
CST Clefts UniCFM Total %
Age
<4 y 1 7 8 9 1 2 28 31.8
47 y 20 8 1 3 32 36.4
712 y 11 4 1 3 19 21.6
>12 y 4 3 1 1 9 10.2
88 100
Surgical technique
Monobloc osteotomy 2 8 8 7 25 26.0
Fronto-orbital osteotomy 2 3 5 5.2
Coronal craniectomy 1 2 3 3.1
Bitemporal parietal craniotomy 1 1 1.0
Le Fort III 31 7 4 8 5 2 57 59.0
Modied midfacial osteotomy* 2 2 2.1
Le Fort II 1 1 1.0
No osteotomy 2 2 2.1
96 100
Distraction rate
1 mm/d 7 6 5 15 5 1 39 40.6
>1 mm/d 27 11 7 1 3 1 50 52.1
<1 mm/d 2 2 3 7 7.3
96 100
Latency period
0 d 26 10 4 1 3 44 53.7
1 d 1 1 1.2
2 d 2 2 2.4
3 d 1 1 3 1 6 7.3
4 d 2 1 1 4 4.9
57 d 7 9 4 3 1 1 25 30.5
82 100
Contention period
3 w 1 1 2 2.6
6 w 1 3 1/1 2 8 10.5
23 m 8/1 10 4 3 2 28 36.8
6 m 16 4 2 14 2 38 50.0
76 100
Devices
External 4 4 2 1 1 1 13 13.5
Internal 32 15 10 18 7 1 83 86.5
95 100
*Osteotomy across the zygomatic arch, and zygomatic body inferior to the inferior orbital rim, across the midface below the inferior orbital
foramen, into the piriform aperture.
procedures through DO below the age of
4 years
18,20
. Dierent distraction rates
were used; 39 patients were distracted at
1 mm daily, 50 patients at more than
1 mm (1.53 mm/d) and 7 patients at less
than 1 mm (0.50.8 mm/d). In the age
group below 4 years of age, 1 mm daily
was the most frequent distraction rate,
while in all other age groups usually a
distraction rate of more than 1 mm daily
was used. Data on distraction rhythm
were reported in only 47 cases (49.0%);
ve patients had a rhythm of 1 mm once
and nine a rhythm of 0.5 mm twice, while
with a distraction rate of more than 1 mm
daily, activation was performed always
two or three times daily. Two patients
who underwent cranial DO through the
use of implantable springs had a continu-
ous distraction rhythm
77
. Latency periods
were reported in 82 cases and ranged from
07 days. A total of 44 patients had a
latency period of 0 days while 25 patients
had a latency period of 57 days. In the
age group below 4 years, a total of 15
patients had a latency period of 57 days,
while in all other age groups no latency
period was the most common. Data re-
lated to the contention period were men-
tioned in 76 patients and ranged from 3
weeks to 6 months; 38 patients had a con-
tention period of 6 months and 28 patients
had one of 23 months. In the age group
below 4 years of age, the 23 month con-
tention period was the most frequent,
while in all other age groups the 6 month
contention period was the most common.
In three patients (3.1%) immediate osteo-
synthesis was made at the end of the acti-
vation period. Data on the obtained
distraction distance were reported in 76
patients (79.2%) and varied from 7.5 to
35 mm; 74 patients were distracted more
than 10 mm. A total of 13 patients (13.5%)
were distracted through the use of external
devices; 10 had monodirectional, 3 multi-
directional devices. In 83 patients (86.5%)
internal devices were used; 80 had mono-
directional, one a bidirectional device and
two implantable springs. Length of follow-
up was reported in 58 patients (60.4%) and
ranged from 2 months to 4 years, with only
36 cases (37.5%) followed-up for 1 year or
longer. Data on relapse were only reported
in 19 cases (19.8%); 17 had no relapse
and two had mild relapse. Information
regarding complications was mentioned
in 87 patients (90.6%); 25 complications
occurred (Table 5).
Under the age of 4 years, it appears
that MB DO is mostly indicated as a
result of functional reasons (respiratory
problems, severe exophthalmos) and
can be performed after a complete MB
osteotomy using internal or external
devices, a 1 mm distraction rate, a 57
latency period and a 23 month conten-
tion period. Midfacial DO is indicated
from the age of 4 years in patients who
underwent early conventional fronto-
cranial remodeling and advancement,
after a complete Le Fort III osteotomy
using the same parameters as the mono-
bloc procedure or using the con-
tinuous rapid midface DO parameters
(Table 11).
Other types of DO of the craniofacial
skeleton
Occasional reports on other types of DO
of the craniofacial skeleton include
zygoma distraction
21
; orbital distrac-
tion
14
, Le Fort II distraction
48
, nasal
bone distraction in hypertelorism
74
and
distraction of scarred soft tissue before
secondary bone grafting
148
.
Discussion
Craniofacial DO is a rapidly growing eld
of craniofacial reconstruction that has be-
come a accepted method worldwide for
the treatment of numerous congenital and
acquired craniofacial anomalies. Clinical
parameters that aect treatment outcome
of craniofacial DO, include: (1) age; (2)
surgical technique; (3) distraction rate and
rhythm; (4) latency period; (5) contention
period and (6) distraction device. Distrac-
tion osteogenesis, parameters, however,
are not rigidly established and consider-
able variation exists between dierent
craniofacial groups. In this article we have
attempted to provide standards for these
variables and to develop treatment proto-
cols for each type of craniofacial DO
based on the review of clinical and ex-
perimental investigations reported in the
literature.
Craniofacial DO has been reported
successfully in the paediatric, adolescent
and adult patient population. Patient age
at the time of distraction is the most im-
portant single variable with potentially
the most profound eect on the outcome
of DO
51
. The human face does not de-
velop as an individual unit but as one
functional unit with growth of one area
depending on growth of the remaining
areas
33
. C:is & S:iir
8
, showed in their
study of mandibular DO in 14 children
with a follow-up of 36 years that cranio-
facial growth postdistraction was vari-
able; this was also observed by other
craniofacial teams
39,51,75
. The growth pat-
tern is modulated by both the original
genetic predispostion of the native bone
as well as the accompanying soft tissue
functional matrix
39,40
. Although the issue
of overcorrection remains controversial,
overcorrection seems to be necessary in
growing patients and younger patients
with greater future growth potential re-
quire a greater amount of overcorrection
than older patients
39,40,86
.
One of the most critical components of
DO is the surgical separation of the bony
fragments. The original Iiiz:ov
5456
concept of necessity of preserving endos-
teumand periosteumhas proved not to be
essential in DO of the human craniofacial
skeleton. The literature on craniofacial
DO, however, is sometimes confusing
regarding the terms corticotomy/osteo-
tomy, especially concerning mandibular
lengthening procedures. Corticotomy is
frequently used, while in reality a com-
plete division of the bone is performed.
Therefore, we interpreted the technique of
performing a corticotomy of the buccal
cortex with a bicortical notch followed by
a peroperative greenstick fracture as a
complete separation of two bone seg-
ments and hence as an osteotomy. In
patients with congenital and acquired
mandibular micrognathia, both an osteo-
tomy and a corticotomy have been per-
formed successfully; 189 patients under-
went an osteotomy (57.3%) and 141
(42.7%) a corticotomy. We suggest that
a complete osteotomy will make the
distraction procedure more reliable,
predictable and comfortable for the
patient.
Table 11. Treatment protocols for midfacial and/or cranial distraction osteogenesis
<4 y Monobloc* 1/d 57 d 23 m I/E
47/712/>12 y Le Fort III 1/d 57 d 23 m I/E
>1/d** 0/d** 6 m** I
Monobloc* 1/d 57 d 23 m I/E
*Monobloc (MB) osteotomy consists of a Le Fort III osteotomy and frontal osteotomy and can
be combined with facial bipartition (FB) in case hypertelorbitism and brachcephaly with facial
atness.
**Continuous rapid midface DO according to Chin and Toth
12,136
: intraoperative advance-
ment up to 10 mm, followed by immediate distraction over 3 to 5 days and a prolonged
contention period.
98 Swennen et al.
The optimal rate of distraction, ac-
cording to adult orthopedic DO, is 1 mm
daily for each callus eld. Faster distrac-
tion rates in enchondral bone result in
local ischaemia in the distraction gap
and delayed ossication or pseudarthro-
sis, whereas slower distraction rates re-
sult in premature ossication and
consolidation
56
. It has been suggested that
the membranous bone of the craniofacial
skeleton behaves dierently and that there
is a risk for premature consolidation if the
distraction rate is too slow, especially in
very young children where faster distrac-
tion rates comparing to DO of the enchon-
dral bones could be necessary
136
. This
review showed that a distraction rate of
1 mm daily remains the standard for man-
dibular lengthening, bone transport and
compression DO and for maxillary ad-
vancement and simultaneous mandibular/
maxillary DO procedures. A total of 451
patients who underwent these procedures
had data on complications; only six
patients (1.3%) had premature consoli-
dation. Although a distraction rate of
1 mm daily is eective in mandibular wid-
ening procedures, most patients (68.4%)
had a rate inferior to 1 mm (0.751 mm/d);
four premature consolidation occurred, al-
though not due to the slower distraction
rate but owing to a failure of the distrac-
tion device. Of the 23 patients that under-
went alveolar reconstruction procedures, a
total of 12 (52.2%) had a distraction rate of
1 mm daily, while 11 (47.8%) had a rate of
0.5 mm daily. None of these patients had
premature consolidation. Furthermore,
this review showed that in midfacial and/or
cranial DO, a distraction rate of 1 mm was
the most frequent in patients under the age
of 4, while in all other age groups, faster
distraction rates (1.53 mm/d) were re-
ported. Pseudarthrosis occurred in none of
the 87 patients who had data on compli-
cations. Success of DO not only depends
on the rate of distraction, but also on the
rhythm. Iiiz:ov
56
showed that osteo-
genic activity was greater when DO was
performed at 0.25 mm four times per day,
as opposed to 1 mm once a day, and even
greater when an autodistractor was used
that allowed continuous distraction. Based
on our analysis of clinical articles on DO,
no conclusions could be made because of
lack of appropriate data regarding distrac-
tion rhythm. We suggest that several acti-
vations (24) a day, however, are certainly
more comfortable for the patient.
According to Iiiz:ov
54,55
success of
DO depends on the response of the initial
callus to tensile stress. Therefore, in the
enchondral bone, a latency period of 57
days after surgery is necessary to allow
time for initial callus formation and heal-
ing of soft tissues
5456
. The membranous
bones of the craniofacial skeleton, which
are thin and have a rich blood supply are
signicantly dierent. Therefore, shorter
latency periods could be acceptable. This
review also showed that in craniofacial
DO the 57 day latency period was the
most frequent. Even longer latency
periods (712 days) were mentioned in
patients who underwent bone transport
and compression DO. On the contrary,
shorter latency periods were reported in
maxillary, midfacial and cranial advance-
ment DO procedures. A 45 day latency
period was most common reported for
maxillary advancement. In the midfacial
and cranial DO group a latency period of
57 days was the most reported in the age
group below 4 years, while in all other age
groups distraction was most frequently
immediately started. However, 38 (63.3%)
of those patients underwent continuous
rapid midface DO after a Le Fort III
osteotomy and were all reported by the
same craniofacial team
10,12,136
. The high
frequency emission of the latency period
is thus not a widely agreed standard, but
results from the high numbers of cases
contributed by a single team. We suggest
that a latency period to allow initial callus
formation and healing of the soft tissues is
also necessary in DO of the craniofacial
membranous bones.
After the active period of distraction,
the distraction appliances are left in place
for adequate consolidation and matur-
ation of the bony callus. This review re-
vealed that the 68 week contention pe-
riod was the most appropriate for all
mandibular lengthening and expansion
DO procedures and for the reconstruction
of segmental defects by bone transport or
compression DO. Longer contention
periods were reported in maxillary (23
months), midfacial and/or cranial DO
(23, 6 months). We suggest that despite
the good vascularization of the midfacial
complex, longer contention periods are
necessary compared to the mandible
owing to the thin structure of the bone at
the distraction sites.
Distraction devices used range from
traditional extraoral monodirectional
appliances as introduced by McC:1nx
et al.
83
to bidirectional
6466,88
and multi-
directional
67,68,85,103,104
devices that per-
mit interceptive distraction. Continued
research has lead to the development
of intraoral devices, that can be
tooth
26,41,60,61,142
, implant
37,38,69
, or
bone
11,29,30,41,47,9193,140
, supported,
and subcutaneous
15,1719
devices used in
midfacial and cranial DO. It is crucial
for the device to be chosen with consid-
eration to the type of skeletal deciency
and the patients needs. Devices with
ideal bone-device and bone-tooth move-
ment ratios of 1:1 are recommended.
Craniofacial DO was found to be a
procedure with low peroperative and
postoperative morbidity. Data on com-
plications were mentioned in 604
(73.0%) of the 828 patients who under-
went craniofacial DO procedures.
Although a total of 133 patients (22.0%)
had complications, most of these were
mechanical problems due to the distrac-
tion appliance or minor local infections
(Table 5). Only four hypertrophic scars
due to external devices and one pseudar-
throsis were reported. It was remarkable
that only two (8%) cases of meningitis
were reported in monobloc DO proce-
dures. All authors noted that this was in
contrast to conventional MB procedures
where the morbidity is higher
17,18,20,136
.
The growing body of literature on
craniofacial DO means that there is a
need for success criteria to provide
objective data in the future. In this
article we attempted to establish such
criteria that should be adequate for
determing long-term functional and
aesthetic results, responding to the needs
of our patients (Table 12). The literature
provides a wide spectrum of useful
tools that can help to increase success,
such as stereolithographic models
112,130
,
3D-cephalometric treatment plan-
ning
75,135
, geometric models
78,110,111,
114,129
, computer-aided surgery
141
, ultra-
sound
35,36,58,80
and endoscopy
109,138
.
The key to success for each type of
craniofacial DO, however, is careful
treatment planning
39,40,111
. Callus
manipulation can be helpful because it
permits ne-tuning of the occlusion
during distraction
44,50,86
.
Craniofacial DO has had an enormous
impact and will probably play a major role
in the future in the treatment of congenital
and acquired deformities of the craniofa-
cial skeleton. Through the use of DO,
craniofacial deformities can be treated less
invasively. Because there is no need for a
second surgical site to harvest bone, oper-
ating time, risk for blood transfusion,
postoperative morbidity and hospital-
ization time are reduced. In addition, sim-
ultaneous expansion of the soft tissue
functional matrix may improve long-term
skeletal stability. The literature dealing
with DOof the craniofacial skeleton, how-
ever, shows a lack of long-term data, es-
pecially regarding skeletal relapse. Only
479 patients (57.9%) had data on
follow-up and in only 248 patients (30%)
information on skeletal relapse was given.
The literature based treatment protocols
proposed in this article certainly have a
bias due to several factors.The increasing
popularity and high concentration of
craniofacial DO congresses and courses
on the international forum, has meant
that clinical parameters are too easily
exchanged between craniofacial teams
without suicient scientic basis. Further-
more, some craniofacial teams reported
results of identical patients in more than
one publication which was analysed in this
study. Hence, the proposed treatment pro-
tocols and success criteria will certainly
require further modication and rene-
ment but can be used in future clinical
studies to provide more objective data.
Future directions in the development of
craniofacial DO include: (1) inuence of
growth factors on DO; (2) eect of DO on
the growing craniofacial skeleton; (3) re-
nement of the osteotomy technique with
endoscopy; (4) development of miniatur-
ized, multidirectional distraction devices
that permit interceptive DO and (5)
modication and renement of cranio-
facial DO treatment protocols.
Conclusion
A review of the literature dealing with DO
of the craniofacial skeleton, provided by a
Pubmed search from 1966 to December
1999 was conducted. With the application
of DO to the membranous bones of the
craniofacial skeleton, a new chapter has
been opened in the surgical treatment of
several congenital and acquired cranio-
facial deformities. This review, however,
revealed a lack of appropriate data on
long-term results and relapse. In the fu-
ture, more clinical studies are necessary
on long-term treatment eects, in terms of
relapse and growth potential of distracted
tissue and on the inuence of the intrinsic
genetic growth deciency.
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Address:
G. Swennen MD, DDS
Department of Oral and Maxillofacial Surgery
Medizinische Hochschule Hannover
Carl-Neuberg-Strasse 1
30625 Hannover
Germany
E-mail: gwen.swennen@gmx.de

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