Distraction Osteogenesis

of the Craniofacial
Skeleton
DR. STUART SUPER
LENOX HILL HOSPITAL
NYU/Bellevue Hospital Center
What is Distraction
Osteogenesis?
The regeneration of bone
between vascularized bone
surfaces that are separated by
gradual distraction
A unique form of clinical tissue
engineering using easily
controlled mechanical
conditions (i.e. slow gradual
distraction of the
corticotomized or
osteotomized bone fragments
History of Distraction
Discovered by accident by
Professor Gavril Abramovich
Ilizarov in 1951
He was treating patients in
Siberia with fractures and
non-unions following WWII
Using a primative external
ring fixator, he compressed
the injured bone ends
together
By chance, one of his patients
reversed the compression rods,
thereby distracting the bone
fragments
Ilizarov observed new bone
formation between the
fragments radiographically and
began experimentation with
distraction clinically
He initially treated fractures
and non-unions, he later cured
cases of chronic osteomyelitis
and developed the techniques
of bone transportation and
limb-lengthening
His work went largely unnoticed until
the 1980s when a group of Italian
orthopedic surgeons headed by Maiocchi
Bianchi dedicated themselves to
understanding and applying his methods
Early craniofacial distraction research focused on
the mandible with experimentation on the canine
mandible, first reported by Snyder in 1973, which
went largely unnoticed until 1989 when McCarthy
presented his canine experiments and first human
applications in Florence in 1989
Principles of Distraction
Osteogenesis
According to Ilizarov, there are two
biological principles that govern distraction
osteogenesis, known as the Ilizarov
Effects:
1) The tension stress effect on the genesis
and growth of tissues
2) The influence of the blood supply and
loading on the shape of bones and joints
Low-energy osteotomy
Duration of latency period
Rate & Rhythm of distraction
Consolidation period
Biological Factors
influencing distraction
During distraction osteogenesis, the normal process of
fracture healing is interrupted by the application of
gradual traction to the soft callus.
Through the application of tensional stress to the
intersegmentary tissues of the soft callus, a dynamic
microenvironment is created.
This environment encourages new tissue formation in a
direction parallel to the vector of traction.
Histomorphologically, the distraction gap can be
represented by four zones:
1) a central zone of fibrous tissue
2) a zone of extending bone formation
3) a zone of bone remodeling, and
4) a zone of mature bone.
Although both of these extraoral maxillary and
mandibular distraction appliances have the
ability to promote significant amounts bone
formation, as well as exhibit excellent vector
control, the primary drawbacks are:
Difficulty with Patient Management
Esthetically Unpleasing

This led to the development of maxillary and
mandibular intraoral distraction appliances
that exhibited similar qualities to the extraoral
distraction appliances, such as vector control,
as well as being more accepted and well
tolerated by patients


Mandibular Distraction
Osteogenesis
Utilizing Intraoral Appliances
Primary Applications:
Patients with Hemifacial Microsomia

Patients exhibiting moderate to severe
micrognathia
Case #1
11 y.o. male with
Hemifacial
microsomia
Facial Asymmetry
Retrognathia
Multiple Ectopic
Teeth
Dental Crowding

Osteotomy for Distraction
Mandibular Zurich
Distraction Appliance
Modified Williams Zurich
Distractor
Case #2
7 y.o. female with
Goldenhar Syndrome
(Hemifacial microsomia
with rib/vertebral
anomalies and systemic
anomalies such as
CNS/cardiac/renal/GI/
pulmonary)
Initial
J une 16, 2003
Case #3
12 y.o. female referred
from NYUCD Ortho for
evaluation and
treatement of her
micrognathic mandible
Maxillary Distraction
Osteogenesis
Utilizing Intraoral Appliances
Primary Applications:

Patients with Moderate to Severe Maxillary
Hypoplasia Requiring 8-15mm of
Advancement

Patients who require a maxillary
advancement procedure and had previously
undergone Cleft Lip and Palate Repair and
have developed large quantities of fibrous
scar tissue
This fibrous scar tissue promotes a high incidence
of relapse when using conventional orthognathic
surgical techniques (eg. Maxillary Advancement)
Intraoral Zurich Maxillary
Distraction Appliance
MAJOR LIMITATION: High Risk of Destruction to the roots of
teeth or developing tooth buds due to the position of the
meshwork
Case #1
23 yr old female
exhibiting a Class III
Malocclusion /
Skeletal Open Bite /
Moderate Maxillary
Hypoplasia /
Prognathism
Previously
Underwent Cleft Lip
and Palate Repair
Treatment Plan
PHASE I:
Maxillary Intraoral Distraction
Advancing the Maxilla Forward and Downward

PHASE II:
Removal of Distraction Appliances
Bilateral Intraoral Vertical Ramus
Osteotomies
Vertical Genioplasty Reduction
Maxillary Trans-Sinusoidal
Distraction Appliance
Problems Encountered with
the Trans-Sinusoidal
Distraction Appliance:
1. Difficulty of achieving parallelism with dual
distraction appliances
2. Quality and Depth of Sinus

15 mm Distraction Arm
3. Thickness of Lateral Maxillary Wall which
serves as anchorage for the appliance

Case #2
19 y.o. male with h/o cleft
lip/palate repair
PSHx: 2001 Lefort I
Osteotomy/B IVRO/ICBG
to close oronasal fistula
=> maxilla relapsed
2002 Attempt to place B
maxillary transsinusoidal
distractors aborted due to
poor quality of bone
2003 Placement of new
maxillary distractor
Before and 12 mos postop
MANDIBULAR CLEFT
34 yr old male with a
h/o cleft mandible
and cleft lower lip
PSxH-repair of cleft lip
and cranial graft
harvest to mandible
2/05 intraoral osseous
distraction

THE END
Thank You