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istraction osteogenesis of the craniofacial skel- orthodontic procedures, the orthodontist has a role in
D eton has become increasingly popular as an
alternative to many conventional orthognathic surgi-
the preoperative assessment of craniofacial skeleton,
evaluation of occlusal function, planning the predis-
cal procedures. For patients with mild to severe traction and postdistraction orthodontics, and the
abnormalities of the craniofacial skeleton, distraction distraction procedure itself. Of particular interest are
techniques have increased the n u m b e r of treatment the questions of relapse, stability, and growth after
alternatives. As in traditional combined surgical/ distraction.
expanded area of the mandible.2,3 The lengthened of mastication, subcutaneous tissue, and skin (func-
bone was evaluated by serial histological examinations tional matrix). Because of the expansion of the associ-
that showed a highly organized biological process. ated soft tissues, there is a resulting multidirectional
There was longitudinal laying down of a collagen expansion of the skeletal and soft tissue envelope. This
scaffold followed by ossification of the collagen bundles soft tissue expansion has been associated with mini-
from the bone edges. It is of interest to note that mal, if any, evidence of skeletal relapse. This is in
conventional rapid palatal expansion across the pala- marked contrast to the predictable relapse associated
tine suture was a precursor to surgically assisted with the traditional methods of surgical elongation of
expansion of the craniofacial skeleton. After prelimi- the severely hypoplastic mandible. Serial radiographic
nary studies in the laboratory documented the feasibil- studies9 conducted on this series of patients showed
ity of mandibular distraction, the authors undertook a that the hypoplastic condylar segment improved in
clinical program in 1989. The initial h u m a n cases of size and orientation and assumed a more normal
mandibular distraction were limited to very young radiographic appearance.
children with severe craniofacial deformity for whom
few surgical alternatives existed. The role of the
orthodontist on the distraction team was gradually
defined over the past 9 years of this clinical experi-
Disadvantages of Distraction
ence.
Osteogenesis
Since the initial report of distraction of the cranio- The most obvious disadvantage of the technique is
facial skeleton by McCarthy et al 3 in 1992, others have residual cutaneous scarring resulting from the transcu-
reported successful distraction of the mandible,4,5 taneous fixation pins. With careful placement of the
midface, 6,7 calvarium, zygomatic arch, and condylar incision, the scar can lie in the lines of minimal
reconstruction, s tension in the submandibular fold. The intraoral
approach for the osteotomy and pin insertion has
evolved as the approach of choice in certain cases in
Indications order to eliminate the scar.
The technique of distraction osteogenesis has been
applied to patients with unilateral craniofacial micro-
somia, bilateral craniofacial microsomia, developmen- Preoperative Clinical Evaluation
tal micrognathia, Treacher Collins syndrome, and
Nager's syndrome. Distraction has also been used for The preoperative clinical examination is similar to the
the correction of midface hypoplasia (craniofacial examination carried out in preparation for orthog-
synostosis syndromes). 6,7 Transport distraction has nathic or craniofacial surgery. The emphasis in this
been shown to be a useful technique for the regenera- article is on the correction of congenital craniofacial
tion (newly forming bone) of the mandibular con- asymmetry.
dyle.s Distraction techniques, no doubt, will be used to The patient should be examined with the head in
correct mild skeletal Class II deformities and, in some an upright position, a goal often rendered difficult
cases, to expand the mandibular symphysis to skel- because of craniofacial asymmetry and head tilt. One
etally correct lower anterior crowding. 5 should note forehead, orbital, zygomatic, and external
ear position and relationships by also viewing the
patient from the "bird's eye" and submental vertex
Advantages of Distraction Osteogenesis positions. In patients with unilateral craniofacial micro-
somia, the position of the oral commissure should be
The 9-year clinical experience has shown that mandibu- documented, and the distance between it and the
lar distraction is a safe and effective surgical tech- external auditory canal (or ear remnant) recorded.
nique. For patients undergoing surgical reconstruc- The position and contour of the chin, inferior border,
tion of the hypoplastic mandible by distraction, the and angle of the mandible are recorded. The external
length of hospitalization and operating time has been ear is graded according to one of several classification
drastically reduced; distraction can even be per- protocols.
formed on an outpatient basis. The technique can be The intraoral examination documents the status of
applied at a younger age (2 years) than is typical for the occlusion. It is important to relate the intraoral
the costochondral rib graft reconstruction. It has pathology to the extraoral skeletal and soft tissue
obviated the need for autogenous bone grafting, as is abnormalities. The occlusal plane or transverse cant
often required in traditional orthognathic surgical should be related to the transorbital plane (Fig 1A), a
procedures. An important benefit is that there is determination later facilitated by examination of the
gradual distraction not only of the bony skeleton, but posteroanterior cephalogram (Fig 1B). Assessment of
also of the associated soft tissues, such as the muscles the transmeatal, transgonial, and midsagittal (verti-
Planning and Biomechanics of Distraction 11
Figure 1. The occlusal plane or transverse occlusal cant can be related to the transorbital and midsagittal planes
(A); a determination later corroborated in examination of the posteroanterior cephalogram (B). Assessment of
the transmeatal, transgonial, and midsagittal (vertical) planes are made on the posteroanterior cephalogram.
Note that the patient's left ear is inferiorly displaced and the ear rod of the cephalostat is resting against the
temporal bone above the ear tag. Abnormal ear position is often present in patients with severe craniofacial
asymmetry. The clinician must make an informed decision regarding placement of the ear rods in these cases (B).
cal) planes are later made on the posteroanterior cial microsomia and microtia, attention must be paid
cephalogram, as well. to placing the head in the correct vertical or midsagit-
The functional clinical examination should in- tal plane when obtaining the cephalograms. 1° As
clude documentation of mandibular excursions, in- shown in Figure 2, the ear rod is positioned in the ear
cluding maximum interincisal opening, because a canal on the unaffected side but is placed on the
transient limitation to opening can occur at the end of calvaria on the affected side. The clinician must
distraction. It is, therefore, important to record the position the head so that the midsagittal plane is
original interincisal opening for use as an objective perpendicular to the floor and the lateral borders of
goal during postdistraction physical therapy. the orbital rims are symmetrically positioned in rela-
The function of the temporomandibular j o i n t be- tion to the lateral borders of the calvarium. This type
fore distraction is documented, and the motor (muscles of precise head positioning must be duplicated in the
of mastication and facial expression) and sensory postoperative period and in all subsequent cephalomet-
(infraorbital, inferior alveolar) nerve functions of the ric recordings. The lateral cephalogram is taken with
patient recorded. the same protocol. Performed in this way, the cephalo-
grams provide a significant advantage over CT scans in
that serial records and long-term studies of growth
Diagnostic Records and development can be carried out.
Craniofacial pathology and asymmetry should be docu- The panorex provides useful information with
mented by standard medical photographs (frontal, regard to the shape and, to a lesser degree, the size of
lateral, oblique, submental, and intraoral). In addi- the condylar heads. In addition, it is useful for visual-
tion, a three-dimensional computed tomographic (CT) ization of the ramus and body of the mandible, as well
scan, lateral and posteroanterior cephalograms, pan- as the position of partially erupted teeth, roots, and
oramic roentgenogram (panorex), and dental study tooth follicles.
models are made. In patients with unilateral craniofa- The landmark data from lateral and posteroante-
12 Grayson and Santiago
Figure 4. Vectors of the lateral and medial pterygoid muscles as they are applied to the mandibular ramus (A).
Vectors of the masseter, temporalis, and suprahyoid muscles applied to the mandible (B). These vectors in
combination with the forces generated by the distraction device will mold the regenerating new bone at the site of
distraction. 1, lat pterygoid; 2, med pterygoid; 3, masseter; 4, temporalis; 5, suprahyoids. (Reprinted with
permission from Grayson BH, Santiago PE: Treatment Planning and Vector Analysis of Mandibular Distraction
Osteogenesis. Atlas Oral Maxillofac Surg Clin North Am 1999:7;1.)
trol originate from activation of the distraction de- tates in a counterclockwise direction, and the lower
vices, their specific orientation to skeletal anatomy, incisors take a more advanced position. A posterior
the application of intermaxillary elastics during the open bite may occur on the side that has undergone
active phase of distraction, and the intercuspation of vertical distraction in the ramus (Fig 6C). Bilateral
the dentition. vertical lengthening of the ramus results in counter-
During the process of planning mandibular distrac- clockwise uprighting of the mandibular symphysis.
tion, it is imperative to consider the powerful impact When combined with the sagittal advancement of the
of both biological and mechanical force systems to mandibular body, the increased prominence of the
anticipate their resultant effects. lower third of the face is evident (Fig 6D). The
A review of clinical records has shown that device unilateral vertical ramal lengthening is usually associ-
orientation to the mandible has a direct influence on ated with transverse correction of the chin position
the change in skeletal morphology. Device placement and the cant correction of the mandibular occlusal
can be described as vertical, horizontal, or oblique. It plane (Fig 7). It is desirable to overcorrect the shape
is important to note that the position of the device is of the growing mandible. The young patient with
best described in relation to the long axis of the greater future growth potential requires a greater
mandibular body (Fig 5). This is in distinction to amount of overcorrection than is required for the
orientation of the devices to the posterior border of older patient?
tile ramus or the inferior border of the body because
of the variability in contour of these borders. When Horizontal Device Placement
there are significant irregularities in the occlusal
plane, the long axis of the mandibular body is the The most efficient approach for achieving sagittal
preferred reference line. projection of the mandibular body and symphysis is by
placement of the distraction device in a horizontal
position in relation to the mandibular body (Fig 8A
Vertical Device Placement
and B). There is a tendency in horizontal distraction
Vertical device placement results in an increase in the of the mandibular body to rotate in a clockwise
vertical dimension of the mandibular ramus (Fig 6A direction, resulting in an open bite 9 (Fig 8C). The
and B). During activation, a change occurs in appli- suprahyoid musculature, in balance with the muscles
ance orientation that appears to be caused by the of mastication and the distraction device itself, has a
nonlinear molding effect of the neuromusculature on role in this occurrence. Improvement in the patency
the regenerate as it is formed. The mandible autoro- of the oropharyngeal airway and tongue position is
14 Grayson and Santiago
Device D e s i g n
1
16 Grayson and Santiago
Figure 9. Intermaxillary
elastics may be helpful in
the reduction of an ante-
rior open bite and may be
used transversely to correct
crossbite or lateral shift of
the mandible during active
distraction. In this illustra-
tion, the mandible has
shifted toward the contralat-
eral side resulting in poste-
rior crossbite. The ipsilat-
]xillary eral side shows open bite.
Cross elastics c o m b i n e d
latal expansion with a mandibular lingual
stabilization arch are used
Cross to correct the crossbite. (Re-
elastics printed with permission
from Grayson BH, Santiago
dibular PE: T r e a t m e n t Planning
ilization arch and Vector Analysis of Man-
dibular Distraction Osteo-
genesis. Atlas Oral Maxillo-
fac Surg Clin North Am
1999:7;1.)
alter the growth rate of the affected mandible after combination of transpalatal arches, lingual arches,
completion of the procedure. The expanded mandibu- intermaxillary cross elastics, and a palatal expansion
lar ramus in a very young child will need considerable devices.
postdistraction growth to achieve full adult dimen- The open bite that is often observed after unilat-
sions. With the expectation that the postdistraction eral distraction results from lowering the mandibular
growth will be syndromic and inadequate to keep up occlusal plane on the affected side while the untreated
with the normal side, there is a need for greater maxilla still has its upward occlusal cant. It is impor-
overcorrection of the ramus in a very young child. 9 tant to prevent relapse of the mandibular occlusal
After completion of activation, the device is main- plane correction through uncontrolled occlusal erup-
rained in position for approximately 8 weeks (consoli- tion of mandibular teeth and alveolus to close the
dation phase). The device is not removed until there is open bite. The open bite is at first maintained by the
radiographic evidence of a cortical outline or mineral- placement of a unilateral posterior bite plate. This bite
ization of the regenerated portion of the mandible. plate is adjusted gradually to achieve eruption of the
The device is removed in the office as an outpatient maxillary teeth and alveolar process down to the level
procedure. Postdistraction photographs, cephalo- mandibular occlusal plane. Over several months, the
grams, panorex, and three-dimensional CT scans of posterior superior surface of the appliance is serially
the mandible are obtained. reduced under individual teeth to allow for their
gradual eruption.
After vertical unilateral distraction of tile mandibu-
Postdistraction Orthodontic
lar ramus, the mandibular body shifts toward the
Management contralateral side, often resulting in posterior cross-
In the unilateral distraction cases, the orthodontist is bites. The crossbite on the expanded side shows the
often confronted with a posterior open bite on the maxillary teeth buccal to the lower teeth. On the
distracted side and a crossbite on the contralateral contralateral side, the maxillary teeth are palatal to
side (Fig 10A). The open bite may be managed with the mandibular teeth (palatal crossbite). The palate
gradual adjustment of a bite plate (Figs 10B, C, and may be expanded to correct the crossbite with a
D). The crossbite resulting from mandibular shift classical palatal expansion device. Maxillary palatal
across the midsagittal plane may be corrected by a expansion is typically a bilateral p h en o m en o n ; thus, as
Planning and Biomechanics of Distraction 19
Figure 10. In the unilateral distraction cases, the orthodontist is often c o n f r o n t e d with a posterior o p e n bite on
the distracted side and a crossbite on the contralateral side. T h e crossbite resulting f r o m m a n d i b u l a r shift across
the midsagittal plane may be c o r r e c t e d by a c o m b i n a t i o n of transpalatal arches, lingual arches, intermaxillary
cross elastics, and a palatal expansion devices (A). T h e o p e n bite may be m a n a g e d with gradual adjustment of a
bite plate worn on either the m a n d i b u l a r or maxillary dentition (B). The bite plate is relieved, one tooth at a time,
u n d e r the occlusal surface of the maxillary posterior teeth. This results in gradual e r u p t i o n of the teeth down to
the level of the c o r r e c t e d m a n d i b u l a r occlusal plane (C, D).
the palatal crossbite is corrected, the buccal crossbite arch (Fig 11). T h e r e are many alternative m e t h o d s of
may worsen. To prevent the latter, intermaxillary cross orthodontically treating the postdistraction patient.
elastics may be w o r n on the side of the buccal
crossbite. The lower molars may be s u p p o r t e d by a Long-Term Postdistraction Change
lingual arch to minimize the tendency for the cross
and Growth
elastic to tip the molar out toward the buccal while the
maxillary molars are tipped to the palatal and into In a longitudinal study, 10 patients with unilateral
i m p r o v e d occlusal relationship with the lower dental craniofacial m i c r o s o m i a and bilateral micrognathia
20 Grayson and Santiago
A B
Figure 11. The lower molars may be supported by a lingual arch to minimize the tendency for the cross elastic to
tip the molar out toward the buccal while the maxillary molars are tipped to the palatal and into improved
occlusal relationship with the lower dental arch (A, B).
who underwent correction of their mandibular defor- tion, the neomandible grew without evidence of re-
mities by distraction osteogenesis were evaluated by lapse during the period of observation. Both sides of
clinical and cephalometric examination.9 The period the mandible grew at similar rates. The unoperated
of postdistraction follow-up ranged from 12 to 70 sites, including the body and condyle, also showed
months. Five patients underwent unilateral mandibu- evidence of growth throughout the study period.
lar distraction and five patients underwent bilateral Comparison of lateral cephalograms showed that a
distraction with an extraoral device. clockwise rotation of the mandible occurred with the
Cephalograms (panoramic, posteroanterior, and passage of time. Clockwise mandibular rotation oc-
lateral) were obtained at the following time points: curred secondary to the expected vertical growth of
preoperative, posttreatment, and annual follow-up. the maxillary dentoalveolus as the children passed
All cephalometric tracings were made on matte ac- from the primary to the mixed and finally to the
etate by a single investigator. The tracings were inde-
p e r m a n e n t dentition. Dental development and erup-
pendently evaluated by two other investigators. Differ-
tion occurred with no evidence of developmental
ences of opinion regarding tracing or landmark
delay.
identification were discussed and resolved among the
The shape of the postdistraction mandible could
three investigators.
be related to variations in the angular relationship
In the period of observation after distraction, the
between the distraction device and the mandibular
10 mandibles showed cephalometric and clinical evi-
body.
dence of growth. In the five unilateral cases, the
unoperated side grew in a pattern as would be ex-
pected for the unaffected side of a mandible with
unilateral craniofacial microsomia. The distracted side, Clinical Presentation
however, grew with a variable response.
Growth occurred at the site of the bone regenerate, An 8-year-old boy with Nager's syndrome presenting
as well as in the adjacent body, ramus, and condylar with underdevelopment of the mandibular body,
head. Minimal relapse was noted in these patients. marked overjet, vertical elongation of the maxillary
The growth response of the operated side was variable dentoalveolar process, and bilateral ear deformity (Fig
and appeared to be dependent on the genetic pro- 12A and B). He underwent bilateral mandibular
gram of the native bone and the surrounding soft distraction (23 mm right and 23 m m left; Fig 12C and
tissue matrix. Morphological and volumetric improve- D). After distraction of the mandible, bilateral cal-
ments previously reported for the condyle were main- varial flaps were used to augment his zygomatic region
tained long term, with continued growth of the and a genioplasty provided additional augmentation
condyle without evidence of deformational changes.15 of the chin. His skin incisions were complicated by the
In the five patients who underwent bilateral distrac- development of hypertrophic scars.
Planning and Biomechanics of Distraction 21
Figure 12. An 8-year-old boy with Nager's syndrome presenting with underdevelopment of the mandibular body,
marked overjet, and vertical elongation of the maxillary dentoalveolar process and bilateral ear deformity (A, B).
After horizontal bilateral mandibular distraction (23 m m right and 23 m m left) (C, D). Note increased forward
projection of the mandibular body and symphysis.
Discussion younger age, has also obviated the need for autog-
enous bone grafting, as is often required in traditional
Mandibular distraction is considered a safe and effec-
orthognathic surgical procedures. This technique has
tive surgical technique. Distraction osteogenesis as a
enabled the surgeon to augment the severely hypoplas-
technique for lengthening the hypoplastic mandible
requires shorter hospitalization than conventional tic mandible in the very young child.
surgical techniques. It can even be performed on an One of the most significant advantages of distrac-
outpatient basis. Blood transfusions are generally not tion osteogenesis is the gradual distraction and length-
required during the placement or removal of the ening of the soft tissues (muscle, subcutaneous tissue,
devices. The technique, which can be used at a and skin) and the functional matrix that surrounds
22 Grayson and Santiago
the bony skeleton. Because of the expansion of the dence of change in sensation of the lower lip. One
associated soft tissues and muscles, there is a resulting must also question the status of the inferior alveolar
multidirectional expansion of the distracted man- nerve in the hypoplastic mandible of patients with
dible. This is characterized by an increase in the unilateral craniofacial microsomia, or if there is in
bigonial distance, an increase in the vertical dimen- reality a functioning inferior alveolar nerve. The
sion of the chin, and often the creation of a better previously described technique makes every effort to
avoid injury to the mandibular canal, and the oste-
defined gonial angle.
otomy (lingual aspect) is performed by a greenstick
The expansion of the soft tissue envelope is be-
fracture.
lieved to contribute to the fact that over 7 years of
The total treatment time approaches 3 months
follow-up, there is minimal, if any, evidence of clinical
with reconstruction of the hypoplastic mandible by
relapse. This is in contrast to the dental/skeletal
distraction, a length of treatment similar to that of
relapse observed after traditional orthognathic ad-
traditional orthognathic mandibular surgery with in-
vancement procedures.
termaxillary fixation before the development of rigid
The gradual (1 m m / d ) rate at which the advance-
skeletal fixation. However, it must be stressed that this
ment/distraction is achieved is another significant
criticism is more than offset by the reduced period of
factor contributing to the minimal relapse. In a
hospitalization and operating time and by the absence
traditional large surgical mandibular advancement,
of discomfort when the device is in place. In addition,
wide subperiosteal u n d e r m i n i n g is often required.
the child is able to eat a regular (soft) diet during
The mobilized segment is advanced against the restric-
the period of treatment. Functional activities of the
tive soft tissues, which is the most significant cause of
mandible (deglutition) and distraction of the muscles
relapse. In the distraction technique, there are two of mastication have a positive influence on the result-
differences from the traditional orthognathic surgical ing morphology of the bony regenerate.
paradigm. First, both the skeletal and soft tissues are The following three variables appear to influence
concomitantly lengthened and secondly the lengthen- the clinical outcome of distraction osteogenesis: (1)
ing is achieved at a gradual rate (1 m m / d ) over an surgical technique and device placement, (2) type of
interval of several weeks. distraction device and its activation, and (3) the role
Another advantage of distraction osteogenesis is of the functional matrix during and after distraction.
that it can be employed as early as 2 years of age
because the technique is relatively simple and bone
grafts are not required to augment the hypoplastic
ramus and body. Surgical Technique and Device
Serial radiographic studies conducted on this se- Placement
ries of patients showed that the hypoplastic condylar The authors practice a true bicortical osteotomy. In
segment improved in size and orientation, assuming a the NewYork technique, the final technical maneuver
more normal radiographic appearance) 5 A concomi- is disruption of the lingual cortex by a greenstick
tant canine laboratory study of changes in the tempo- fracture. Pin placement establishes the positioning of
romandibularjoints after unilateral mandibular distrac- the distraction device and the latter dictates, to a great
tion showed that there was a transient posterior extent, the vector of distraction (modified, of course,
condylar flattening of the ipsilateral side and postero- by the functioning muscles of mastication). In unilat-
superior flattening on the contralateral side. There eral and bilateral mandibular deficiencies, the pathol-
was histological evidence of subchondral degenera- ogy is usually located predominantly in the ascending
tion followed by repair and remodeling, the latter ramus. Consequently, the goal is vertical elongation of
resulting in a correction of the condylar flattening. 16 the ramus with or without horizontal elongation of the
One of the disadvantages of the extraoral distrac- body. In most of the unilateral cases, the pins/device
tion technique is the residual cutaneous scarring but have been inserted along a predominantly vertical
with careful placement of the incision, the scar can lie vector with a more oblique position of the device in
in the lines of minimal tension in the submandibular the bilateral cases in which sagittal thrust of the body
fold. The intraoral approach for the osteotomy/pin and chin is also desired (oblique vector). A horizontal
insertion has, however, evolved as the approach of vector is used in bilateral cases in which only anterior
choice because of reduction in the size of the scar. It mandibular projection is required. With the develop-
can be anticipated that miniaturized intraoral devices ment and introduction of multidirectional devices,
will also be developed in the future. more flexibility will be available for control of the
There has also been concern about injury to the distraction trajectory in the vertical, sagittal, and
inferior alveolar nerve, a potential complication with horizontal directions. However, unidirectional devices
all mandibular osteotomies. Questioning of older will still be used when only vertical elongation of the
patients has failed to detect any postoperative evi- ascending ramus (with leveling of the occlusal plane
Planning and Biomechanics of Distraction 23
and oral commissure) is sought. T h e authors' longitu- t r e a t m e n t team. T h e traditional role of the o r t h o d o n -
dinal studies have also shown that, especially in bilat- tist has b e e n and continues to be one of documenta-
eral cases, vertical elongation of the ramus is also tion and evaluation of growth, description of the
associated with counterclockwise rotation of the man- presenting deformity, growth prediction, and evalua-
dible with anterior projection of the body and chin. 9 tion of occlusion, facial proportions, and esthetics.
This type of correction will be facilitated by the newer T h r o u g h careful assessment of the clinical, radio-
multidirectional devices that can be m a n i p u l a t e d in graphic, and p h o t o g r a p h i c records, the orthodontist
the x, y, and z planes. and surgeon will plan the m a g n i t u d e and direction of
the desired change. A t r e a t m e n t plan will e m e r g e after
collaboration and discussion with selected m e m b e r s
Distraction Device Characteristics
of the t r e a t m e n t team. In this institution (New York
Serial radiographic studies of unidirectional devices University Medical Center, New York, NY and the
have shown a change in the device vector d u r i n g and University of Puerto Rico School of Dentistry, San
after active distraction, a finding that has b e e n attrib- J u a n , PR), the orthodontist meets jointly with the
uted to the role of the muscles of mastication on the patient and surgeon to m o n i t o r and evaluate progress
newly f o r m e d bony regenerate. T h e introduction of a d u r i n g the active phase of distraction. Postdistraction
multidirectional device provides m o r e control in o r t h o d o n t i c m a n a g e m e n t begins shortly after removal
achieving: (1) the f u n d a m e n t a l vertical elongation of of the devices.
the ramus, (2) horizontal elongation (body) and Distraction osteogenesis of the craniofacial skel-
recreation of the m a n d i b u l a r angle with control over e t o n has o p e n e d up significant new possibilities for
the incisor vertical bite relationships ( o p e n bite, the t r e a t m e n t of severe, as well as mild, skeletal
closed bite), and (3) transverse w i d e n i n g or increase deformities. It is e x p e c t e d that the ability to compen-
in the bigonial distance. sate for mild skeletal growth abnormalities will be
Intraoral devices, offering the decided advantage significantly e n h a n c e d with the advent of efficient and
of avoiding an external cutaneous scar, will find m o r e precision minidistraction devices. These appliances
application in the bilateral deficiencies (microgna- will be b u r i e d u n d e r the skin and will be adjusted with
thia) in which there is sufficient b o n e stock for device small transcutaneous screws. Thus, the surgeon and
p l a c e m e n t and w h e n a horizontal vector is optimal. In orthodontist have b e c o m e collaborators in a process
the cases of unilateral distraction with severe ramal that gradually alters the direction and m a g n i t u d e of
deficiency and the n e e d for a vertical vector, the craniofacial growth.
extraoral device is still preferred.
References
Role of the Functional Matrix
1. Ilizarov GA. The tension-stress effect on the genesis and
A surprising finding is the multidimensional changes growth of tissues: The influence of stability of fixation
in m a n d i b u l a r skeletal f o r m achieved with a unidirec- and soft-tissue preservation. Clin Orthop 1989;238:249-
tional distraction device. For example, increases in the 281.
transverse or bigonial distance and in the vertical 2. Karp NS, McCarthyJG, SchreiberJS, Sissons HA, Thorne
dimension of the c o r o n o i d process have b e e n ob- CH. Membranous bone lengthening: A serial histologic
served. It appears that the masticatory muscles work study. Ann Plast Surg 1992;29:2-7.
on the bony r e g e n e r a t e and thus significantly modify 3. McCarthyJG, SchreiberJ, Karp N, Thorne CH, Grayson
BH. Lengthening of the human mandible by gradual
changes in m a n d i b u l a r form. Bony r e m o d e l i n g occurs
distraction. Plast Reconstr Surg 1992;89:1-8.
p r e d o m i n a n t l y d u r i n g and after distraction while the 4. Molina F, Ortiz Monasterio E Mandibular elongation
patient is functioning with deglutition, mastication, and remodeling by distraction: A farewell to major
and speech. osteotomies. Plast Reconstr Surg 1995;96:825-840.
Gradual distraction or lengthening, n o t only of the 5. Guerrero CA. Intraoral mandibular distraction osteogen-
skeleton, but also the muscular and cutaneous tissues, esis.J Oral Maxillofac Surg 1992;199:115.
probably accounts for the absence of relapse previ- 6. PolleyJW, FigueroaAA. Management of severe maxillary
ously a p p a r e n t after b o n e grafting of the ramus in deficiency in childhood and adolescence through distrac-
unilateral craniofacial microsomia and o r t h o g n a t h i c tion osteogenesis with an external, adjustable, rigid
surgical a d v a n c e m e n t for the correction of severe distraction device.J Craniofac Surg 1997;8:181-186.
7. Cohen SR, Rutrick RE, Burstein E Distraction osteogen-
m a n d i b u l a r micrognathia.
esis of the human craniofacial skeleton: Initial experi-
ence with a new distraction system: J Craniofac Surg
Conclusion 1995;6:368-374.
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