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YIJOM-2688; No of Pages 8

Int. J. Oral Maxillofac. Surg. 2013; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2013.05.004, available online at http://www.sciencedirect.com

Clinical Paper

Orthognathic Surgery

1 2

T. H. El-Bialy , Y. Razdolsky ,

3 4

N. D. Kravitz , S. Dessner ,

Long-term results of bilateral 5,6

R. F. Elgazzar

1

Orthodontics and Biomedical Engineering,

Faculty of Medicine and Dentistry, University

mandibular distraction of Alberta, Edmonton, Alberta, Canada;

2

Private Orthodontic Practice, Buffalo Grove,

3

IL, USA; Private Orthodontic Practice,

4

osteogenesis using an intraoral Chantilly, VA, USA; Private Oral and

Maxillofacial Surgery Practice, Schaumburg,

5

IL, USA; Oral and Maxillofacial Surgery

Division, Faculty of Dentistry, University of

6

tooth-borne device in adult Manitoba, Canada; Oral and Maxillofacial

Surgery, Tanta University, Egypt

Class II patients

T. H. El-Bialy, Y. Razdolsky, N. D. Kravitz, S. Dessner, R. F. Elgazzar: Long-term

results of bilateral mandibular distraction osteogenesis using an intraoral tooth-

borne device in adult Class II patients. Int. J. Oral Maxillofac. Surg. 2013; xxx: xxx–

xxx. # 2013 International Association of Oral and Maxillofacial Surgeons. Published

by Elsevier Ltd. All rights reserved.

Abstract. The aim of this prospective clinical study was to evaluate the short-term and

long-term skeletal and dental changes after mandibular osteodistraction with tooth-

borne appliances in adult orthodontic patients. The sample consisted of 10 non-

growing Caucasian patients with a Class II skeletal relationship due to mandibular

deﬁciency, together with Class II dental malocclusion. All patients underwent

mandibular distraction osteogenesis (MDO) using the ROD1 tooth-borne device.

Lateral cephalograms were evaluated at four time intervals: pretreatment (T1), after

mandibular distraction (T2), after orthodontic ﬁxed appliance therapy (T3), and at

long-term observation 8-year post-distraction (T4). Statistical analyses compared

the skeletal and dental changes in intervals T1–T2, T2–T3, T3–T4, T1–T4, and T2–

T4. MDO with the ROD1 tooth-borne device produced signiﬁcant long-term (T1–

T4) increases in the SNB angle (2.38), total mandibular length (5.9 mm), and corpus

length (4.5 mm). Potential adverse sequelae included signiﬁcant increases in

mandibular plane angle (4.38), lower anterior dental height (2.8 mm), and lower

Key words: tooth-borne detractor; mandibular

posterior dental height (2.5 mm). Signiﬁcant increases in lower incisor proclination

retrognathia; distraction osteogenesis; long

occurred during distraction (7.58). Distraction osteogenesis with tooth-borne term.

appliances offers a minimally invasive surgical method with stable results for

correcting mandibular deﬁciency in non-growing patients. Accepted for publication 14 May 2013

Introduction advancement surgery, including bilateral joins surgically divided bone segments,

sagittal split or vertical ramus osteotomies. has become an important alternative surgi-

The orthodontic treatment of adult Class II Distraction osteogenesis (DO), the biologi- cal technique for the craniofacial region.

patients with mandibular retrognathia often cal process of new bone formation by gra- Mandibular DO (MDO) is frequently per-

entails dental camouﬂaging or mandibular dually stretching the healing callus that formed in young children with congenital

0901-5027/000001+08 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: El-Bialy TH, et al. Long-term results of bilateral mandibular distraction osteogenesis using an

intraoral tooth-borne device in adult Class II patients, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.05.004

YIJOM-2688; No of Pages 8

2 El-Bialy et al.

craniofacial skeletal deformities including

1–9

severe micrognathia, as well as children

and adults with ankylosis of the temporo-

10–13

mandibular joint (TMJ) to elongate the

mandible, improve function, and enhance

the soft tissue proﬁle. However, MDO is

performed less often in adult Class II

patients for skeletal correction of mandib- 14,15

ular retrognathia.

The advantages of MDO compared to

the conventional orthognathic surgery

include: enables extensive bone lengthen- Fig. 1. ROD1 device assembled (A) and disassembled (B).

16

ing ; eliminates the need for bone graft-

16 17 18

ing and inter-maxillary ﬁxation ; the Hamada et al. presented a case report two adult Class II patients (mean age 29

incremental skeletal movements allow for of bilateral MDO using a bone-borne years) with TMJ ankylosis and retro-

15

accommodation of the soft tissues ; appliance for the treatment of obstructive gnathia (mean SNB = 638). At a mean

18

reduces surgical stress ; and reduces sleep apnea syndrome (OSAS) in a 31- 15 months post-distraction, the authors

the incidence of inferior alveolar nerve year-old male with severe retrognathia reported a mean 138 increase in SNB from

19–21

dysesthesia. The primary disadvan- (SNB = 67.48). At the end of distraction, the pretreatment value, despite a mean

tages of MDO include: the total length of the cephalometric analyses revealed a 2.88 4.5 mm of relapse in mandibular length.

treatment, which may take up to 3–4 decrease in ANB, a 3.08 increase in man- In 1997, Razdolsky introduced the

months to ensure adequate stabilization dibular plane angle (MPA), a 7.68 increase ROD1 (Oral Osteodistraction, LP, Buf-

16,18

of the regenerate, and the potential for in lower incisor angulation, and a 3.5 mm falo Grove, IL, USA), a tooth-borne dis-

20

bite opening. increase in LL to E-line. After 3 years and traction device for multiplanar interdental

25

The appliances used for MDO can be 1 month of post-distraction orthodontic distraction (Fig. 1). The main indica-

categorized with regard to whether they treatment, followed by 9 months in reten- tions for using ROD1 are in cases with

are internal or external, the direction of tion, ANB relapsed slightly (0.98) and the skeletal Class II due to mandibular deﬁ-

22

distraction, and the site of application. mandibular incisors further proclined ciency, especially when accompanied by

External devices are inserted through the (1.28), while the MPA remained constant. lower incisor crowding and/or ﬂaring in

24

skin to the mandible. These devices are Karacay et al. presented a case report horizontal growth pattern. Currently, no

capable of extensive distraction and multi- of MDO using the MD-DOS bone-borne prospective clinical study has evaluated

dimensional control; however they are appliance in a 20-year-old male with a the long-term effects of bilateral antero-

conspicuous and bulky, and more likely hyperplastic maxilla (SNA = 868, posterior MDO using a tooth-borne appli-

to cause traction scarring on the face. ANB = 68) and excessive overjet ance in non-growing patients. The pur-

Internal or intraoral devices are attached (16 mm). At the end of consolidation pose of this study was to evaluate the

either to bone or less commonly to teeth (10 weeks after distraction at the time of long-term skeletal and dental changes

adjacent to the osteotomy site. Some device removal), the cephalometric ana- after antero-posterior mandibular distrac-

devices are attached to teeth and bone lyses revealed a 48 decrease in ANB, an tion using the tooth-borne ROD1 distrac-

(known as hybrid devices), thereby pro- 11 mm increase in total effective mandib- tion device in Class II adult orthodontic

viding both direct and indirect skeletal ular length, a 6 mm increase in corpus patients.

ﬁxation. Most internal distractors are cap- length, a 78 increase in y-axis, a 158

22

able of unidirectional distraction only. increase in lower incisor angulation, and

Materials and methods

Internal devices are less visible than exter- 4 mm increase in LL to E-line. At the 1-

nal devices and will not cause scarring, year follow-up appointment (17 months The sample for this study consisted of 10

though they are often limited to the extent after removal of the distraction device), consecutively treated adult patients (seven

22

and direction of distraction and the dis- ANB relapsed 28, total mandibular length males, three females) from a private ortho-

traction rod may create excessive pressure relapsed 4 mm, corpus length relapsed dontic practice, who underwent mandibular

20

on the lower lip. 2 mm, y-axis returned to the original pre- advancement distraction osteogenesis using

In regards to intraoral devices, tooth- treatment value, lower incisors maintained the ROD1 tooth-borne device. All patients

borne distraction offers numerous advan- their proclination, and the lower lip main- presented with a Class II skeletal relation-

tages in comparison to bone-borne distrac- tained protrusion relative to the E-plane. ship (mean ANB = 6.68) due to mandibular

17

tion, including: eliminates the need for a Mattick et al. presented three case retrognathia (mean SNB = 73.28), Class II

second surgery to remove the distraction reports of bilateral mandibular advance- dental malocclusion (mean molar relation-

14

bone Plates ; the distraction screws are ment by MDO using the intraoral bone- ship = 1.4 mm, overjet = 8.0 mm, lower

removable which maximizes the surgical borne device in Class II adult patients crowding of 5.1 Æ 1 mm, lower incisor

access; and interdental distraction osteo- (mean age 22 years). At the end of ﬁxed inclination relative to mandibular plane of

tomies and seating of the device are per- orthodontic treatment (4–7 months post- 94.6 Æ 78), and average curve of Spee. All

23

formed in an outpatient setting, which distraction), cephalometric analyses patients had mesocephalic facial types and

minimizes operation time, surgical mor- revealed a mean 4.78 decrease in ANB, normal forward and backward growth of the

14

bidity, and hospital expenses. Despite a mean 11.1 mm increase in total effective mandible. Sample demographics included

these advantages, the current literature mandibular length, and a 1.88 decrease in Caucasian patients from either ﬁrst- or sec-

regarding bilateral intraoral MDO in adult lower incisor angulation. ond-generation Eastern-European descent.

12

patients has mainly been focused on bone- Sadakah et al. performed bilateral The inclusion criteria for patient selec-

borne or hybrid appliances. MDO using a bone-borne appliance in tion included: (1) Class II skeletal

Please cite this article in press as: El-Bialy TH, et al. Long-term results of bilateral mandibular distraction osteogenesis using an

intraoral tooth-borne device in adult Class II patients, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.05.004

YIJOM-2688; No of Pages 8

Long-term results of tooth-borne MDO 3

relationship due to mandibular retro- older patients); (2) distraction rate of times. Figure 5 shows cephalometric

gnathia, (2) Class II dental malocclusion, 1.0 mm/day; (3) distraction rhythm of superimposition of the average values of

(3) non-growing adult patient, with (4) three turns per day (0.33 mm/1808 turn) the 10 patients at different treatment times.

healthy periodontium. Prior to enrollment, until proper length was attained; (4) Descriptive statistics and statistical

all patients were presented three treatment moulding of the regenerate with an elastic comparisons for cephalometric skeletal

options: (1) non-surgical dental camou- chin-cup appliance, worn a minimum of and dental changes at the four treatment

ﬂage with or without upper premolar 14 h per day, to counteract downward pull intervals are presented in Tables 1 and 2.

extraction, (2) mandibular advancement of the suprahyoid muscles on the anterior At the end of distraction (T1–T2), signiﬁ-

via bilateral sagittal split osteotomy, or segment; (5) consolidation for 6 weeks cant increases occurred in the SNB angle

(3) mandibular interdental distraction after the last day of distraction; (6) (1.98), total mandibular length (5.0 mm),

using the ROD1 tooth-borne distraction removal of the ROD1 appliance after corpus length (4.6 mm), MPA (5.38),

device. All patients chose the third option, radiographic evidence of bone formation lower incisor proclination (7.98), lower

i.e., mandibular interdental distraction or calciﬁcation of the callus (conﬁrmed by anterior dental height (1.3 mm), lower

using the ROD1 tooth-borne distraction panoramic radiographs); (7) delay of 2–3 posterior dental height (2.7 mm), and

device. additional months for bone remodelling lower lip protrusion (1.4 mm).

Prior to fabrication of the tooth-borne along with continued wear of the elastic By the debonding appointment (T2–

distraction appliance, presurgical ortho- chin-cup before initiating orthodontic T3), signiﬁcant decreases had occurred

dontic tooth alignment was performed tooth movement through the new regen- in lower incisor angulation (À14.78) and

with 0.018 slot prescription twin brackets erate. Arch coordination was performed lower lip protrusion (À3.6 mm); however,

and ﬁrst molar bands. The purpose of the during the postsurgical orthodontics. The lower anterior dental height continued to

presurgical orthodontics was to provide retention protocol involved upper fixed 2– increase significantly. No significant

the surgeon with enough interdental space 2, lower ﬁxed 3–3, Upper Essex retainer changes occurred in the antero-posterior

to perform the surgical cuts without risk- and ﬁxed retainers in the distraction areas. position of the mandible, MPA, corpus

ing trauma to the neighbouring teeth. After Inferior alveolar nerve sensation was length, total mandibular length, or lower

building to 0.016 Â 0.022 stainless steel assessed using a two-point contact test posterior dental height. At the 8-year post-

wires, the maxillary and mandibular on the lower lip before and at 3–6 months distraction follow up (T3–T4), no signiﬁ-

26

arches were coordinated. The lower ﬁrst after distraction. cant changes had occurred from the

premolars and second molars were ﬁtted Lateral cephalometric radiographs were debonding appointment. Comparison of

with preformed stainless steel crowns collected at four time intervals: T1, pre- T2–T4 revealed statistical differences

(3 M Unitek, Monrovia, CA, USA), and treatment; T2, end of distraction; T3, end only between T2 and T4 in the lower

alginate impressions were taken to transfer of ﬁxed appliances; and T4, 8 years after incisor angulation and in the lower lip

the bands to a heat-resistant stone model ﬁnishing orthodontic treatment. Lateral protrusion, consistent with T2–T3.

for laboratory processing. Patients were cephalometric superimpositions were per- When comparing the long-term changes

prepared before surgery by the orthodon- formed for each patient using Dolphin from the presenting pretreatment cephalo-

tist who cemented the male component of Imaging 10.0 (Dolphin Imaging Solutions, metric analyses (T1–T4), signiﬁcant

the ROD1 appliance on the teeth adjacent Chatsworth, CA, USA) by an independent increases had occurred in the SNB angle

to the distraction site using glass ionomer orthodontist. Superimposition was per- (2.38), total mandibular length (5.9 mm),

cement (Fuji Ortho LC, GC America, Inc., formed on the outlines of the anterior corpus length (4.5 mm), MPA (4.38), as

Alsip, IL, USA). cranial base and registered on the centre well as lower anterior and posterior dental

All patients were treated surgically by of the sella. Statistical analyses using heights (2.8 mm and 2.5 mm, respec-

the same oral maxillofacial surgeon. Each paired t-tests compared the skeletal and tively). The lower incisors were proclined

surgery was performed in an outpatient dental changes between intervals T1 and (7.58) during distraction; however they

setting under local anaesthesia and intra- T2, T2 and T3, T3 and T4, T1 and T4, and were uprighted by the end of the active

venous sedation. Bilateral mandibular cor- T2 and T4. Subsets of ﬁve radiographs orthodontic treatment. There were no

ticotomies were performed between the were digitized by the same investigator noted changes in the gingival architectures

mandibular second premolar and the ﬁrst over a period of 2 weeks and comparison or gingival recession at the end of treat-

molar or the ﬁrst and second molar using a of the two measurements was performed ment or at T4.

reciprocating saw. Lateral corticotomies by paired t-test. There was no signiﬁcant The degree of association between

extended vertically from the inferior bor- difference at the P = 0.05 level of signiﬁ- variable changes during treatment was

der to a point just inferior to the alveolar cance, revealing the measurements to be evaluated (Table 3). There was a strong

crest, and transversely through the corpus reliable. correlation between total anterior facial

without perforating the lingual cortical height (TAFH) changes and the changes

plate to prevent damage to the lingual in mandibular corpus length (Go–Gn),

Results

nerves and vessels. A parallel lingual cor- mandibular total length (Cd–Gn), and

ticotomy was made extending from the The mean pretreatment sample age was mandibular plane inclination to Frank-

mylohyoid ridge convexity to a point just 24.7 years (males 25.4, females 23.9) with furt horizontal plane (MPA). Also, there

short of the lingual alveolar crest. The an age range of 16–34 years. Inferior alveo- was a strong association between the

lingual cortex was separated with an lar nerve sensory tests revealed that there changes in y-axis and lower anterior

osteotome to perform a complete osteot- was no difference between the before and facial height (LAFH) that conﬁrmed

omy before placing the female component after distraction values for all the patients, the increased facial height. Further, there

of the distractor. indicating that the inferior alveolar nerve was a strong association between the

The distraction protocol was as follows: was not affected by the procedure. changes in lower incisor inclination to

(1) 5 and 7 days postsurgery latency period Figures 2–4 show clinical records of MPA and lower lip position relative to

(5 days for younger patients and 7 days for one of the patients at different treatment the E-plane.

Please cite this article in press as: El-Bialy TH, et al. Long-term results of bilateral mandibular distraction osteogenesis using an

intraoral tooth-borne device in adult Class II patients, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.05.004

YIJOM-2688; No of Pages 8

4 El-Bialy et al.

Discussion

The purpose of this preliminary prospec-

tive clinical study was to evaluate the

short-term and long-term effects of bilat-

eral tooth-borne osteodistraction for Class

II correction in adult patients. The ﬁnal

data collection was performed in Decem-

ber 2006. The mean length of active dis-

traction was 15 Æ 5 days. The average

period of orthodontic treatment post-dis-

traction was 14.6 Æ 9 months.

The total mandibular length and corpus

length increased 5.0 mm and 4.6 mm,

respectively, during osteodistraction and

remained stable throughout long-term

retention. The amount of distraction was

slightly less than previously reported in

17,24

bone-borne studies. However, less

skeletal relapse occurred in comparison

to previous bone-borne studies with

12,24,27

shorter post-distraction recalls.

Furthermore, skeletal relationships in all

patients in our study were corrected during

distraction and maintained Class I canine

during the 8-year follow-up.

Despite the increase in mandible length,

the SNB angle only increased 1.98 during

distraction, which is less than previous

reports using bone-borne appliances.

The modest increase in antero-posterior

position of the mandible during the dis-

traction phase was likely inﬂuenced by the

opening rotation of the mandible. Karacay

24

et al., for example, reported a mean 68

increase in SNB despite a 78 increase in

20

the y-axis. van Strijen et al. reported that

the antero-posterior position of B-point

was likely to relapse in high-angle

patients. In our study, the SNB angle

did not decrease after distraction; how-

ever, greater antero-posterior position of

the mandible would have likely been

achieved with better vertical control.

The MPA increased 5.38 during distrac-

tion and remained relatively constant dur-

ing the 8-year follow-up period. These

results are consistent with similar previous

18,24

bone-borne studies. For example,

18

Hamada el al. reported a 38 increase

in the MPA during distraction, which

remained almost constant after distraction.

28

However, Gonzalez et al. reported a 4.18

increase in MPA during distraction and

2.78 of further opening rotation during the

consolidation period, which was likely a

result of muscular pull on the developing

callus. In this study, the opening rotation

that occurred during distraction was likely

a combination of signiﬁcant posterior den-

tal extrusion and poor compliance with the

Fig. 2. Clinical extraoral photographs for one of the patients: preoperative (A), immediately

elastic chin-cup in a few patients. It could

after ﬁnishing distraction (B), after ﬁnishing orthodontic treatment (C), and 8 years in retention

(D). also be argued that the consolidation per-

iod is the main reason for the increase in

Please cite this article in press as: El-Bialy TH, et al. Long-term results of bilateral mandibular distraction osteogenesis using an

intraoral tooth-borne device in adult Class II patients, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.05.004

YIJOM-2688; No of Pages 8

Long-term results of tooth-borne MDO 5

Fig. 3. Clinical intraoral photographs of the patient in Fig. 2: preoperative (A), immediately after ﬁnishing distraction (B), after ﬁnishing

orthodontic treatment (C), and 8 years in retention (D).

MPA secondary to removing the appliance increased incisor mandibular plane angle back into proper occlusal position. The

before complete mineralization occurred, (IMPA). efﬁcacy of regenerate moulding is well

and the created interdental space was The elastic chin-cup functions to reduce documented; however, there exists some

closed by reciprocal forces while the the MPA and control bite opening in two debate regarding the proper timing, dura-

suprahyoid muscles exerted important ways: the vertical compression minimizes tion, and method of callus manipulation.

29

relapse pressure allowing clockwise man- pull from the suprahyoid muscles and Wei et al. advocated moulding the

dibular rotation. This also could contribute moulds the immature regenerate, both of regenerate during the consolidation phase,

30

to the relapse in the inferior border and the which help guide the distracted segment whereas McCarthy et al. and Peltomaki

Fig. 4. Lateral cephalometric and panoramic X-rays of the patient in Figs. 2 and 3: preoperative (A), immediately after ﬁnishing distraction (B),

after ﬁnishing orthodontic treatment (C), and 8 years in retention (D).

Please cite this article in press as: El-Bialy TH, et al. Long-term results of bilateral mandibular distraction osteogenesis using an

intraoral tooth-borne device in adult Class II patients, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.05.004

YIJOM-2688; No of Pages 8

6 El-Bialy et al.

Fig. 5. Mean cephalometric changes: superimposition at different treatment times.

31

et al. advocated manipulation during the consolidation period. Signiﬁcant increases with the use of a tooth-borne appliance.

activation phase. Regenerate moulding is in bite opening and dental extrusion The posterior dental extrusion opened the

typically achieved by attaching intermax- occurred during the distraction phase, bite, weakened the antero-posterior posi-

illary elastics or orthodontic springs to and only slight closure of the MPA was tion of B-point, and impeded the improve-

maxillary archwire; however, this method observed after removal of the distraction ment of the Class II facial proﬁle. The

can result in signiﬁcant incisor extrusion. device. amount of extrusion for the lower ﬁrst

In our study, the regenerate was moulded There was noticeable extrusion of the molar was more than twice that of the

with an elastic chin-cup during active anterior and posterior dental height during lower incisor. Posterior dental extrusion

distraction and throughout the 6-week the distraction period, which was expected was likely a result of the proximity of the

Table 1. Descriptive statistics for the cephalometric analyses at the four time (T) intervals (N = 10).

T1 T2 T3 T4

Mean SD Mean SD Mean SD Mean SD

Cephalometric variables

SNA (8) 79.9 3.6 79.8 3.6 79.7 3.5 79.8 3.6

SNB (8) 73.2 3.7 75.1 3.8 75.5 3.8 75.6 3.8

ANB (8) 6.6 3.7 4.7 3.1 4.3 2.6 4.2 2.6

MPA (8) 23.9 6.8 29.2 6.7 28.6 7.1 28.2 6.6

y-axis (SGn–FH) (8) 60.9 4.9 61.8 4.3 61.3 4.4 61.3 4.2

Go–Gn (mm) 63.6 7.9 68.2 5.2 68.8 4.5 68.2 5.3

Cd–Gn (mm) 95.7 6.1 100.7 5.5 101.6 5.3 101.6 5.4

TAFH (NaMe) (mm) 105.5 3.6 110.5 4.1 110.5 4.9 110.3 4.9

LAFH (%) 53.5 3.0 55.5 2.7 55.5 2.2 55.2 2.4

LAFH (ANS–Me) (mm) 58.8 3.8 63.5 3.4 63.2 3.2 62.9 3.3

IMPA (8) 94.6 7.9 102.5 8.5 87.8 4.1 87.1 7.5

LADH (mm) 36.4 1.7 37.7 2.4 39.1 2.1 39.2 2.1

LPDH (mm) 27.7 1.6 30.4 1.9 29.8 2.1 29.9 2.3

LL–E line (mm) À1.0 1.9 0.4 2.4 À3.2 2.0 À3.0 2.6

SNA, sella–nasion–A point; SNB, sella–nasion–B point; ANB, A-point–nasion–B point; MPA, mandibular plane angle; SGn, sella–gnathion; FH,

Frankfurt horizontal; Go, gonion; Gn, gnathion; Go–Gn, mandibular corpus length; Cd, condyle; Cd–Gn, mandibular total length; TAFH, total

anterior facial height; NaMe, nasion to menton; LAFH, lower anterior facial height; IMPA, incisor mandibular plane angle; LADH, lower anterior

dental height; LPDH, lower posterior dental height; LL–E line, lower lip protrusion–aesthetic line.

Please cite this article in press as: El-Bialy TH, et al. Long-term results of bilateral mandibular distraction osteogenesis using an

intraoral tooth-borne device in adult Class II patients, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.05.004

YIJOM-2688; No of Pages 8

Long-term results of tooth-borne MDO 7

Table 2. Statistical comparisons for cephalometric changes at the four time (T) intervals.

T1–T2 T2–T3 T3–T4 T1–T4 T2–T4

Mean SD P-value Mean SD P-value Mean SD P-value Mean SD P-value Mean SD P-value

Cephalometric variables

*

SNA (8) À0.1 0.1 0.012 0.0 0.3 0.601 0.1 0.3 0.199 0.0 0.3 0.719 0.1 0.3 0.515

* *

SNB (8) 1.9 1.8 0.011 0.4 1.0 0.218 0.1 0.3 0.466 2.3 2.0 0.005 0.5 1.2 0.232

* *

ANB (8) À1.9 1.8 0.009 À0.5 1.2 0.677 À0.1 0.4 0.705 À2.4 2.0 0.005 À0.4 1.4 0.338

* * *

MPA (8) 5.3 1.6 0.000 À0.6 1.2 0.152 À0.4 0.6 0.066 4.3 2.4 0.000 À1.0 1.2 0.035

y-axis (SGn–FH) (8) 0.9 1.3 0.045 À0.6 1.2 0.160 0.0 0.4 0.943 0.4 2.3 0.619 À0.5 1.3 0.218

* *

Go–Gn (mm) 4.6 3.4 0.002 0.5 2.3 0.474 À0.6 1.5 0.234 4.5 3.4 0.002 À0.1 2.2 0.933

* *

Cd–Gn (mm) 5.0 2.6 0.000 0.9 1.3 0.055 0.0 0.7 0.892 5.9 2.9 0.000 0.9 1.7 0.109

* *

TAFH (NaMe) (mm) 5.0 1.8 0.000 0.0 1.6 0.969 À0.1 0.7 0.552 4.8 2.7 0.000 À0.2 1.8 0.780

* *

LAFH (%) 2.0 0.7 0.000 À0.1 0.7 0.785 À0.3 0.3 0.049 1.7 1.0 0.000 À0.3 0.7 0.182

* *

LAFH (ANS–Me) (mm) 4.7 1.6 0.000 À0.4 1.6 0.517 À0.3 0.7 0.234 4.1 2.5 0.001 À0.6 1.7 0.267

* * * *

IMPA (8) 7.9 5.8 0.006 À14.7 7.6 0.000 À0.7 3.1 0.769 À7.5 6.3 0.005 À15.4 6.7 0.000

* * *

LADH (mm) 1.3 1.8 0.024 1.4 2.0 0.080 0.1 0.6 0.833 2.8 1.1 0.000 1.5 1.7 0.022

* *

LPDH (mm) 2.7 1.3 0.000 À0.6 1.3 0.260 0.1 0.5 0.684 2.5 1.7 0.005 À0.4 1.2 0.308

* * *

LL–E line (mm) 1.4 2.9 0.272 À3.6 1.5 0.000 0.3 1.2 1.0 3.1 2.6 0.023 À3.3 2.1 0.001

SNA, sella–nasion–A point; SNB, sella–nasion–B point; ANB, A-point–nasion–B point; MPA, mandibular plane angle; SGn, sella–gnathion; FH,

Frankfurt horizontal; Go, gonion; Gn, gnathion; Go–Gn, mandibular corpus length; Cd, condyle; Cd–Gn, mandibular total length; TAFH, total

anterior facial height; NaMe, nasion to menton; LAFH, lower anterior facial height; IMPA, incisor mandibular plane angle; LADH, lower anterior

dental height; LPDH, lower posterior dental height; LL–E line, lower lip protrusion–aesthetic line.

*

Signiﬁcant comparison, P < 0.05.

distraction device, whereas the anterior likely a result of protracting the lower or orthodontic springs may eliminate the

dental extrusion may have occurred as a second molar into the distraction space. social burden of wearing an extraoral

sequela of bite opening. The slight relapse The strong association between the appliance, control the force level, and

in posterior dental height, which occurred increased y-axis and lower as well as total eliminate the need for patient compliance.

by the end of ﬁxed appliances, corre- anterior facial heights conﬁrms the slight (3) Over the length of the study, two

sponded with the slight closure in MPA. increase in the vertical dimension after different radiography machines were

The lower incisors were proclined 7.98 distraction. This could be due to the used, one ﬁlm and the other digital; this

during the distraction and were uprighted increased lower anterior and posterior may have resulted in tracing and super-

by the completion of the ﬁxed appliances. dental heights after distraction, as evi- imposition errors. (4) Cone-beam com-

The signiﬁcant advancement and proclina- denced by the strong association between puted tomography scans may have

tion of the lower incisors was consistent TAFH changes and lower anterior dental provided better insight into the period-

18,24

with previous bone-borne studies. The height (LADH) as well as with lower ontal health of the lower incisors during

uprighting of the lower incisors was greater posterior dental height (LPDH) changes. distraction. It is probable that the signiﬁ-

than described in previous reports, and was The strong association between the cant incisor proclination that occurred

changes in the lower incisor inclination during distraction may have inﬂuenced

to MPA and lower lip position relative to the periodontium since we did not witness

Table 3. The degree of association between the E-plane indicates that lower incisor any gingival recession even after T4.

variable changes during treatment as evalu- position is important for facial aesthetics. Based on this study, we can conclude

ated by T1–T4. There were several signiﬁcant limita- that tooth-borne MDO could be used as an

* tions to this study. (1) Most signiﬁcantly, alternative to orthognathic surgery for

Cephalometric variables r P-value

the treatment results were not compared to cases with a skeletal Class II relationship

TAFH and Go–Gn 0.91 0.0001

a control group. Future studies are needed together with Class II malocclusion. Also,

TAFH and Cd–Gn 0.87 0.001

to make comparative evaluations between future studies might be aimed to evaluate

TAFH and MPA 0.69 0.03

the long-term effects of bilateral tooth- the possibility of root resorption with

LAFH and Go–Gn 0.75 0.011

Cd–Gn and Go–Gn 0.89 0.001 borne MDO to dental camouﬂaging or orthodontic treatment using tooth-borne

y-axis and MPA 0.77 0.01 conventional mandibular advancement distraction devices. It should be noted that

TAFH and LADH 0.83 0.003 surgery with more complex mandibular cost and time are two important factors,

TAFH and LPDH 0.85 0.002 movements than 10 mm, which is particularly in busy clinics and with self-

LL–E line and L1/MPA 0.64 0.047

expected to be associated with counter- paid patients. However, the DO technique

TAFH, total anterior facial height; Go, clockwise mandibular movements. (2) is not meant to replace the current well-

gonion; Gn, gnathion; Go–Gn, mandibular Patient compliance with the elastic established orthognathic techniques,

corpus length; Cd, condyle; Cd–Gn, mandib- chin-cup was not recorded with a daily rather it may be considered as a useful

ular total length; MPA, mandibular plane

log. The increase in MPA and dental reliable technique in selected candidates.

angle; LAFH, lower anterior facial height;

extrusion indicate that actual compliance Another recommendation to improve the

LADH, lower anterior dental height; LPDH,

may have been less than reported by the patient’s proﬁle with compromised aes-

lower posterior dental height; LL–E line,

patients. Future studies are needed to thetics when noticed with most of the

lower lip protrusion–aesthetic line; L1, lower

determine the proper timing and appro- DO techniques used for the treatment of central incisor.

*

Correlation coefﬁcient (r) for the rela- priate force for regenerate moulding. In Class II patients, is that advancement

tionship between variable changes during addition, the incorporation of temporary genioplasty can easily be done separately

treatment. anchorage devices with inter-arch elastics if it is indicated.

Please cite this article in press as: El-Bialy TH, et al. Long-term results of bilateral mandibular distraction osteogenesis using an

intraoral tooth-borne device in adult Class II patients, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.05.004

YIJOM-2688; No of Pages 8

8 El-Bialy et al.

It can be suggested within the limita- 8. Perlyn CA, Schmelzer RE, Sutera SP, Kane 20. van Strijen PJ, Breuning KH, Becking AG,

tions of the current study that intraoral AA, Govier D, Marsh JL. Effect of distrac- Perdijk FB, Tuinzing DB. Complications in

distraction using tooth-borne distraction tion osteogenesis of the mandible on upper bilateral mandibular distraction osteogenesis

airway volume and resistance in children using internal devices. Oral Surg Oral Med

devices appears to be predictable and

with micrognathia. Plast Reconstr Surg Oral Pathol Oral Radiol Endod 2003;96:

stable. No complications were seen in

2002;109:1809–18. 392–7.

the treated samples compared to published

9. Rhee ST, Buchman SR. Pediatric mandibular 21. Westermark A, Bystedt H, von Konow L.

complications with other bone-borne dis-

distraction osteogenesis: the present and the Inferior alveolar nerve function after sagittal

traction devices.

future. J Craniofac Surg 2003;14:803–8. split osteotomy of the mandible: correlation

The results of this study may help clin-

10. Gabbay JS, Heller JB, Song YY, Wasson KL, with degree of intraoperative nerve encoun-

icians to select the correct surgical inter-

Harrington H, Bradley JP. Temporomandib- ter and other variables in 496 operations. Br J

vention and proper appliance according to

ular joint bony ankylosis: comparison of Oral Maxillofac Surg 1998;36:429–33.

the planned treatment, in terms of amount

treatment with transport distraction osteo- 22. Maull DJ. Review of devices for distraction

of movement, age of the patient, occlusal

genesis or the Matthews device arthroplasty. osteogenesis of the craniofacial complex.

plane, and preserving the inferior alveolar

J Craniofac Surg 2006;17:516–22. Semin Orthod 1999;5:64–73.

nerve (movements over 20% of the man-

11. Cascone P, Agrillo A, Spuntarelli G, Arangio 23. Dessner S, Razdolsky Y, El-Bialy T, Evans

dibular body length should be done ante- P, Iannetti G. Combined surgical therapy of CA. Mandibular lengthening using prepro-

rior to the nerve, or sagittal split temporomandibular joint ankylosis and sec- grammed intraoral tooth-borne distraction

distraction). ondary deformity using intraoral distraction. devices. J Oral Maxillofac Surg 1999;57:

J Craniofac Surg 2002;13:401–9. discussion 1318–22. discussion 1322–1323.

410. 24. Karacay S, Akin E, Okcu KM, Bengi AO,

Funding

12. Sadakah AA, Elgazzar RF, Abdelhady AI. Altug HA. Mandibular distraction with MD-

American Association of Orthodontists Intraoral distraction osteogenesis for the cor- DOS device. Angle Orthod 2005;75:685–93.

Foundation. rection of facial deformities following tem- [25] Razdolsky Y. Intraoral tooth borne distrac-

poromandibular joint ankylosis: a modiﬁed tion osteogenesis device (ROD). Proceed-

technique. Int J Oral Maxillofac Surg ings of the First International Symposium

Competing interests 2006;35:399–406. on Distraction Processes. June 1997.

None. 13. Yoon HJ, Kim HG. Intraoral mandibular 26. Campbell RL, Shamaskin RG, Harkins SW.

distraction osteogenesis in facial asymmetry Assessment of recovery from injury to infer-

patients with unilateral temporomandibular ior alveolar and mental nerves. Oral Surg

Ethical approval joint bony ankylosis. Int J Oral Maxillofac Oral Med Oral Pathol 1987;64:519–26.

Surg 2002;31:544–8. 27. van Strijen PJ, Breuning KH, Becking AG,

Institutional Review Board of the Univer-

[14] Razdolsky Y, Pensler J, Dessner S, Skeletal Tuinzing DB. Stability after distraction

sity of Illinois at Chicago.

distraction for mandibular lengthening with osteogenesis to lengthen the mandible:

a completely intraoral toothborne distrac- results in 50 patients. J Oral Maxillofac Surg

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Please cite this article in press as: El-Bialy TH, et al. Long-term results of bilateral mandibular distraction osteogenesis using an

intraoral tooth-borne device in adult Class II patients, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.05.004

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