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Pamela R, Hanson, DDS, MS to Distract Or Not Distract in the Surgical/Orthodontic

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Pamela R, Hanson, DDS, MS to Distract Or Not Distract in the Surgical/Orthodontic Pamela R, Hanson, DDS, MS To Distract or not Distract in the Surgical/Orthodontic I. Definition of Distraction Osteogenesis a. Distraction osteogenesis is a process that results in new bone formation between the surfaces of bone segments gradually separated by incremental traction. b. The volume of soft tissue adjacent to the generating bone is also increased c. Histiogenesis i. occurs in different tissues: ii. bone, skin, fascia, blood vessels, 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. Understanding Distraction Osteogenesis a. What it can and can’t do i. Can do: 1. Lengthen bones 2. Increase volume of bones 3- dimensionally 3. Increase the soft tissue envelope 4. Decrease relapse Linear distraction device (above) (below)3 dimensional volume increase of right side of dog mandible following distraction utilizing the above linear distraction device images from : Karp NS,et al. Membranous bone lengthening: a serial histological study. Annals Plast Surg 1992:29:2-7. ii. Cannot do: 1. Make bones shorter 2. Make bones smaller 3. Move bones backwards III. To Distract or not distract is the question a. To Distract-When to consider distraction as a treatment modality i. If magnitude is too great for any other procedure ii. If function demands early and/or large magnitude correction iii. If stability is better with DO iv. If it sets up the patient for a more stable and precise definitive procedure at skeletal maturity v. If skill of the team can deliver an excellent result b. Not to Distract-When distraction is not the recommended option i. If magnitude is not great and other procedures are more precise. ii. If skeletal correction required is to retroposition a bone or decrease skeletal volume iii. If no functional deficit iv. If other procedures provide good/better stability v. If skill of the team cannot deliver an excellent result 1. Surgical skill/experience inadequate 2. Skilled orthodontist unavailable for: a. Treatment planning b. Monitoring the active distraction c. Manipulating the distal segment vi. If a patient is incapable of cooperation IV. Team Effort is required to successfully complete distraction a. Diagnosis i. Identifying the deficiency 1. Skeletal 2. Soft tissue ii. Identify location of the deficiency iii. Identify the differences between: 1. Volume a. 3 dimensional value 2. Location a. Advancing a skeletal structure (A-P) b. Placing the distal segment in a precise 3 dimensional location c. Vertically manipulating the skeletal structure i. Improves overall result ii. ie: Le Fort III advancement 1. Improves occlusion-ie closes anterior openbite 2. Increases orbital volume vertically by lowering the orbital floor 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. Surgical skill i. Accuracy in corticotomy/osteotomy c. Device placement i. Accuracy in placement position ii. Symmetry-if bilateral device placement iii. Ideal vector established d. Protocol-should be carefully followed to maximize outcome i. Ilizarov-1949-1st protocol with low morbidity 1. Latency period a. 5-7 days prior to device activation b. Fibrovascular matrix formation 2. Rate/rhythm a. 1mm/day b. 1mm/day completed by several increments per day 3. Consolidation a. Length-Roughly twice the of number of days of activation b. When radiographic evidence of bone consolidation e. Active distraction i. 1mm/day f. Control of distraction is crucial i. Preparation 1. Treatment plan a. Determine final position of bone b. Determine magnitude of desired distraction in mm c. Determine length of distraction device at least 2X that of the desired length of distraction in mm 2. Orthodontic preparation a. Anchorage i. To provide the opportunity to manipulate the distal segment b. Distraction stabilization appliances i. To provide multiple places for elastic traction ii. To provide maxillary expansion PRN Hanson PR, Melugin MB. Orthodontic management of the patient undergoing mandibular distraction osteogenesis. Seminars in Orthodontics. March 1999: 5(1):25-34. g. During distraction-control is crucial i. Activation of the distraction device 1. Millimetric lengthening-linear 2. Device manipulation only if devices is multidirectional ii. Forces/manipulation of the distal segment 1. Elastic traction 2. Maxillary expansion h. After consolidation i. Elastic traction ii. Maxillary expansion iii. Occlusal plane correction via adjusted bite block (figure below) 1. Sequential adjustment of the biteblock to promote sequential eruption of the maxillary posterior teeth 2. Closes the posterior openbite created by distraction of the mandible to the desired vertical by supererupting the maxillary posterior teeth to correct the maxillary occlusal plane and close the distraction created openbite. Illustration by Dr Barry Grayson i. Requirements i. Cooperation by the patient crucial ii. Team treatment -control/forces can be placed by someone who will assume that role 1. Educate patient and family 2. Monitor closely the advancing/evolving distraction iii. Knowledge/experience on how to diagnose, deliver forces and monitor V. Parameters when considering distraction as a treatment option a. Magnitude i. Determining magnitude helps determine the following: 1. If distraction is the best modality 2. Device type 3. Device length b. Timing i. Timing based on functional need ii. Timing because magnitude so great a single definitive procedure would not be successful iii. Timing as the first step to a 2 step definitive surgical/orthodontic plan c. Functional disorders that drive timing i. Airway, ii. Masticatory function-Chewing/feeding iii. Speech iv. Facial appearance v. Psychosocial development d. Therapeutic benefit e. Maxillary DO after alveolar cleft graft as maxilla is single piece post graft VI. Unique to Distraction a. Shape forming effect b. Altered phenotypic expression of fibroblasts c. Fibroblasts “polarize” orienting parallel to the vector of distraction i. Changes the direction of the fibroblast orientation ii. This in turn changes the phenotypic expression of the fibroblast iii. Which changes the shape of the bone and ultimately the position of the bone d. Forces placed on the distal segment during distraction e. Types of forces Hanson PR, Melugin MB. Orthodontic management of the patient undergoing mandibular distraction osteogenesis. Seminars in Orthodontics. March 1999: 5(1):25-34. i. Distraction device activation or alteration of a multidimensional distraction device ii. Elastic traction iii. Headgear iv. Expansion appliances v. Distraction stabilization appliances VII. Maxillary hypoplasia a. Le Fort III/midface deficiencies b. Le Fort I/maxillary deficiencies VIII. Unilateral Mandibular distraction IX. Bilateral Mandibular distraction Pamela R. Hanson, DDS, MS Orthodontic Director Cleft & Craniofacial Teams Children’s Hospital of Wisconsin Surgical/ Orthodontic Director, Div. of Oral & Maxillofacial Surgery, Medical College of Wisconsin Faculty, Marquette University School of Dentistry, Department of Orthodontics, Diplomat of the American Board of Orthodontics. Citations: AAO To Distract or Not Distract 1. Abbot, L. C. The operative lengthening of the tibia and fibula. J. Bone Joint Surg. 9: 128, 1927. 2. Annino, D. J., Goguen, L. A., and Karmody, C. S. Distraction osteogenesis for reconstruction of mandibular symphyseal defects. Arch. Otolaryngol. Head Neck Surg. 120: 911, 1994. 3. Aronson, J., Good, B., Stewart, C., Harrison, B., and Harp, J. Preliminary studies of mineralization during distraction osteogenesis. Clin. Orthop. 250: 43, 1990 4. Aronson, J., Harrison, B., Boyd, C. M., Cannon, D. J.,Lubansky, H. J., and Stewart, C. Mechanical induction of osteogenesis: Preliminary studies. Ann. Clin. Lab. Sci. 18: 195, 1988. 5. Aronson, J., Harrison, B., Boyd, C. M., Cannon, D. J., and Lubansky, H. J. Mechanical induction of osteogenesis. J. Pediatr. Orthop. 8: 396, 1988. 6. Arnoson, J., and Shen, X. Experimental healing of distraction osteogenesis comparing metaphyseal with diaphyseal sites. Clin. Orthop. 301: 25, 1994. 7. Aro, H. Biomechanics of distraction. In J. G. McCarthy, (Ed.), Distraction of the Craniofacial Skeleton. New York: Springer-Verlag, 1999. Pp. 20-50. 8. Brighton, C. T., and Hunt, R. M. Early histological and ultrastructural changes in medullary fracture callus. J. Bone Joint Surg. (Am.) 73: 832, 1991. 9. Califacno, L., Cortese, A., Zupi, A., and Tajana, G. Mandibular lengthening by external distraction: An experimental study in the rabbit. J. Oral Maxillofac. Surg. 52: 1179, 1994. 10. Carls F, Sailer H. Seven years’ experience with mandibular distraction in children. J Craniomaxillofac Surg 1998;26:197Y208 11. Castero, H. J., and Salyer, K. E. Regenerative potential of bone and periosteum. Surg. Forum 26: 555, 1975. 12. Centrella, M., McCarthy, T. L., and Canalis, E. Current concepts review: Transforming growth factor beta and remodeling of bone. J. Bone Joint Surg. (Am.) 73: 1418, 1991. 13. Civelek B, Karamursel S, Ozdil K, et al. A potential complication with an extraoral distractor for mandible lengthening: facial nerve paralysis.
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