Distraction Osteogenesis

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Distraction osteogenesis is a process that results in the creation of new bone in an enlarging gap between two bone fragments caused by their gradual separation (59). Originally described by Codivilla (1904) for lengthening lower extremity bones, the process gained wider acceptance after Gavril Ilizarov, a Russian surgeon, studied the mechanics and physiology of limb lengthening in 1954. Dr. Ilizarov continued his work and has contributed much of the current clinical knowledge of the method and biology of distraction osteogenesis (60-62).

Three methods of distraction osteogenesis are described: monofocal, bifocal, and trifocal. Monofocal distraction is the separation of two fragments of bone with one focus of new bone formation between the fragments (e.g., limb lengthening). Bifocal distraction is the movement of a single bone fragment or what is termed a transport disk, cut from the remaining bone stump, across a gap to unite with the opposite native bone (Fig. 7). Trifocal distraction is the movement of two apposing disks across a gap (e.g., advancing osteotomized mandibular body segments for sym-physeal reconstruction. (63).

The method of distraction osteogenesis for maxillofacial application is extrapolated largely from the experiences with long bone distraction. First, division of the bone cortex (corticotomy) is required, preserving the medullary blood supply (e.g., inferior alveolar artery) and the periosteum. A latent period of up to 15 days (shorter for younger patients) is required for adequate callus formation and regeneration of central vessels and periosteal tissue. The external distraction device is connected to the underlying bones percutaneously via pins attached to a threaded bar for manual separation. Internalization of the distraction device to avoid cutaneous scarring has recently been studied (64). New bone formation occurs in -g the distracted mandible by intramembranous ossification. Distraction results in new bone formation induced by the combination of stretching and compressive forces by functional activity, referred to by Ilizarov as the tension-stress effect. The surrounding soft tissue envelope is concurrently expanded. The ideal rate of distraction was determined by Ilizarov in canines to be 1 mm/day in 0.25 mm incre- 3

ments. A slower rate of distraction resulted in premature union, and a faster rate resulted in delayed or nonunions. Osteogenic activity at the callous is greatest with continuous distraction; however, distracting in 0.25 mm increments results in satis- §

factory new bone formation.

Distraction Osteogenesis Mandible

Indications for distraction osteogenesis in the maxillofacial region include treatment of the following:

Transverse maxillary deficiency (65) and congenital mandibular hypoplasia

(e.g., hemifacial microsomia) (66) Treacher Collins syndrome for tracheotomy decannulation (67) Mandibular defects from tumor resection or trauma Sagittal maxillary deficiency secondary to cleft palate Craniosynostoses (59)

Potential complications using distraction in the facial region include premature union, nonunion, elongated cutaneous scars, and patient intolerance of the device. Even very minor movement, other than the controlled daily distractions, can lead to fibrous nonunion or cartilage formation. Although the effects of radiation on distraction require further study, Gantous et al. successfully distracted irradiated canine mandibles (68). Neurosensory disturbances in the cheek (infraorbital nerve) after maxillary distraction or in the chin (inferior alveolar nerve) after mandibular distraction can occur early in distraction, but resolve over time (69).


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