Thirty Years Later: What Has Craniofacial Distraction Osteogenesis Surgery Replaced?

LEARNING OBJECTIVES: After studying this article and viewing the video, the participant should be able to: 1. Compare the relative stability and neurosensory changes following mandible distraction osteogenesis with those after traditional advancement and fixation. 2. Describe the condylar changes that can occur after mandible distraction osteogenesis and list three ways to mitigate these changes. 3. Propose clinical situations where segmental or rotational movements of the midface may allow improved outcomes compared to en bloc linear distraction advancement. 4. Summarize the advantages and risks associated with anterior and posterior cranial distraction osteogenesis compared to traditional one-stage expansion. SUMMARY: Over the past 30 years, distraction forces have been applied to the spectrum of craniofacial osteotomies. It is now time to assess critically the current understanding of distraction in craniofacial surgery, identifying both traditional procedures it has replaced and those it has not. This article provides a review of comparative studies and expert opinion on the current state of craniofacial distraction compared with traditional operations. Through this critical evaluation, the reader will be able to identify when distraction techniques are appropriate, when traditional techniques are more favorable, and what the future of distraction osteogenesis is.

Neonatal Micrognathia: National Trends in Early Mandibular Surgery.

BACKGROUND: Micrognathia is a congenital anomaly that may pose breathing and feeding limitations in newborns, sometimes necessitating invasive management. The present study aims to identify the complications associated with receiving mandibular surgery during the birth stay in order to better predict which patients may benefit from early surgical intervention. METHODS: A retrospective cohort study was performed using the 2000 to 2012 kids' inpatient databases. We included all live newborn infants born in the hospital through vaginal delivery or caesarean section. We used multivariate logistic regression to investigate the demographic and clinical factors associated with receiving mandibular surgery for micrognathia during the birth stay. RESULTS: Of 19,638,453 births, 999 were diagnosed with micrognathia (0.005%). Forty (4%) patients with micrognathia underwent mandibular surgery during the initial admission. On univariate analysis in newborns with micrognathia, mandibular surgery during birth stay was associated with cleft palate, apnea, intubation, tracheostomy, obstructive sleep apnea (OSA), and long mechanical ventilation. Multivariate analysis supported the association between mandibular surgery during the initial admission and long mechanical ventilation (odds ratio [OR], 24.6; 95% confidence interval [CI], 7.7-78.5), OSA (OR, 24.9; 95% CI, 2.5-261.8), apnea (OR, 4.2; 95% CI, 1.5-11.3), and cleft palate (OR, 4.6; 95% CI, 2.0-10.6). However, intubation and tracheostomy were not found to be associated with early mandibular surgery during the birth stay. CONCLUSIONS: The present study identified long mechanical ventilation, apnea, cleft palate, and OSA as factors indicating patients who may benefit from early mandibular surgery, such as mandibular distraction osteogenesis. These findings may bring the clinician closer to standardizing the indications for early mandibular distraction osteogenesis.

Publication Trends in Craniofacial Distraction: A Bibliometrical Analysis.

PURPOSE: The purpose of this study was to analyze the craniofacial distraction literature published over the last 50 years and to determine various trends in publications. METHODS: A literature search was conducted in November and December 2015. The date search range was 1965 to 2015. Databases searched included Medline, Web of Science, Biosis, SciELO, Data Citation, and Zoologic Records. Data were collected on distraction type, author specialty, date of publication, country, state (if United States), number of citations, journal name, journal type, and Le Fort type (for midfacial distractions). RESULTS: Total number of craniofacial distraction publications was 1729. Cranial distraction accounted for (11%), midfacial (11%), and mandibular (78%). Largest increase in publications was in the 1990s, with 48 publications from 1991 to 1995 rising to 261 publications from 1996 to 2000. Among the cranial distraction publications, Plastic and Reconstructive Surgery (PRS) (67%) were the most frequent authors but among the midfacial and mandibular distraction publications, Oral and Maxillofacial Surgery (OMFS) were the most frequent authors (68% and 64%, respectively). Total number of citations was 26,281 with OMFS (50.4%) and PRS (37%) being cited most frequently. Oral and Maxillofacial Surgery was cited most for mandibular and midfacial distraction, and PRS was cited most for cranial distraction. CONCLUSION: Research on craniofacial distraction has significantly increased since the 1970s, with mandibular distraction accounting for the majority of this rise. Among specialties, OMFS and PRS account for the majority of the literature. The United States leads the publication. Authors tend to publish distraction literature in their corresponding journal specialty, with the exception of PRS who publishes most frequently in OMFS journals.

Mandibular Tissue Engineering: Past, Present, Future.

Almost 2 decades ago, the senior author's (M.T.J.) first article was with our mentor, Dr Leonard B. Kaban, a review article titled "Distraction Osteogenesis: Past, Present, Future." In 1998, many thought it would be impossible to have a remotely activated, small, curvilinear distractor that could be placed using endoscopic techniques. Currently, a U.S. patent for a curvilinear automated device and endoscopic techniques for minimally invasive access for jaw reconstruction exist. With minimally invasive access for jaw reconstruction, the burden to decrease donor site morbidity has increased. Distraction osteogenesis (DO) is an in vivo form of tissue engineering. The DO technique eliminates a donor site, is less invasive, requires a shorter operative time than usual procedures, and can be used for multiple reconstruction applications. Tissue engineering could further reduce morbidity and cost and increase treatment availability. The purpose of the present report was to review our experience with tissue engineering of bone: the past, present, and our vision for the future. The present report serves as a tribute to our mentor and acknowledges Dr Kaban for his incessant tutelage, guidance, wisdom, and boundless vision.

Avance maxilar en pacientes fisurados labio palatinos con distractor intraoral / Maxillary advancement in cleft palate patients with intraoral distraction

Introducción. Los pacientes fisurados labio palatinos presentan con frecuencia hipoplasia maxilar. La osteogénesis por distracción (DO) de maxilar superior es una técnica alternativa para pacientes con hipoplasia maxilar severa. Se han evaluado los cambios producidos en tejidos duros y blandos y su estabilidad en el tiempo. Material y métodos. Se ha realizado DO de maxilar a 6 pacientes (5 mujeres y un hombre) fisurados labio palatinos, entre 16-25 años, con un distractor interno. Hemos evaluado mediante trazados cefalométricos en radiografías y fotografías los cambios esqueléticos y en tejidos blandos. El tiempo de seguimiento fue entre 2-8 años. Resultados. En 5 pacientes el punto A avanza entre 3-10 mm mejorando significativamente las relaciones maxilo-mandibulares. En un paciente fracasa la DO intraoral y se termina el caso con RED; en un paciente se evidencia poco avance y rotación maxilar. La recidiva observada entre 6-9 meses post DO es entre el 10 y el 15% tanto esquelética como en tejidos blandos. Conclusiones. La DO intraoral es una técnica alternativa exitosa para avance del maxilar en pacientes fisurados labio palatinos que necesiten un avance inferior a 10 mm. Produce mejoras en el perfil esquelético y blando. Los dispositivos internos no producen impacto psicológico. La contención más larga en el tiempo. La recidiva es difícil de definir y calcular (AU)

Introduction. Patients with cleft lip and palate usually present with maxillary hypoplasia. Upper jaw intraoral distraction osteogenesis (DO) is an alternative technique for patients with severe maxillary hypoplasia. An evaluation was made of the changes produced in hard and soft tissues and their stability over time. Material and methods. Six patients (5 female and 1 male) between 16 and 25 years old with cleft lip and palate underwent maxillary DO with an internal distractor. An evaluation was made of the skeletal and soft tissues changes using cephalometric studies with radiographs and photographs. Follow-up time was between 2 and 8 years. Results. There was Point A advancement between 3-10 mm in 5 patients, significantly improving maxillomandibular relationships. Intraoral DO failed in one patient, and the case was finished using rigid external distraction (RED). In another patient hardly any advancement and maxillary rotation was observed. The relapse observed between 6 and 9 months post DO was between 10-15% in both skeletal and soft tissues. Conclusions. Intraoral DO is a successful alternative technique in maxillary advancement in patients with cleft lip and palate who need an advancement less than 10 mm. It produces improvements in the skeletal and soft profile. Internal devices do not have any psychological impact and have longer consolidation phases. Relapse is difficult to determine and calculate (AU)

Impact of surgical innovation on tissue repair in the surgical patient.

BACKGROUND: Throughout history, surgeons have been prolific innovators, which is hardly surprising as most surgeons innovate daily, tailoring their intervention to the intrinsic uniqueness of each operation, each patient and each disease. Innovation can be defined as the application of better solutions that meet new requirements, unarticulated needs or existing market needs. In the past two decades, surgical innovation has significantly improved patient outcomes, complication rates and length of hospital stay. There is one key area that has great potential to change the face of surgical practice and which is still in its infancy: the realm of regenerative medicine and tissue engineering. METHODS: A literature review was performed using PubMed; peer-reviewed publications were screened for relevance in order to identify key surgical innovations influencing regenerative medicine, with a focus on osseous, cutaneous and soft tissue reconstruction. RESULTS: This review describes recent advances in regenerative medicine, documenting key innovations in osseous, cutaneous and soft tissue regeneration that have brought regenerative medicine to the forefront of the surgical imagination. CONCLUSION: Surgical innovation in the emerging field of regenerative medicine has the ability to make a major impact on surgery on a daily basis.

[CURRENT PROGRESS OF CLINICAL THERAPY FOR HEMIFACIAL MICROSOMIA].

OBJECTIVE: To summarize the current progress of clinical therapy for hemifacial microsomia (HFM). METHODS: The domestic and overseas articles concerning the treatment of HFM were reviewed and analyzed. RESULTS: The unified therapeutic schedule of HFM has not yet been determined due to its variable clinical manifestation. Therapies mainly include: correction of bone deformity, which attain high effectiveness by adopting distraction osteogenesis or the improvement approach based on it; repair of the hypoplasia of facial soft tissue using graft of free tissue or autologous fat, augmentation of prosthesis materials. Autologous fat is becoming a hot research area and is widely used in recent years. For the aspect of treatment of microtia, different methods are adopted according to the severity of the malformation. CONCLUSION: The uniform clinical diagnosis and therapy of HFM are not determined for its complicated classification and unknown etiology. The research of etiology and tissue engineering may provide the therapy of HFM.

Motorized intramedullary nail for management of limb-length discrepancy and deformity.

Distraction osteogenesis has been used for more than 50 years to address limb-length discrepancy and deformity. Intramedullary fixation has been used in conjunction with external fixation to decrease the time in the external fixator and prevent deformity and refracture. A new generation of motorized intramedullary nails is now available to treat limb-length discrepancy and deformity. These nails provide bone fragment stabilization and lengthening with reliable remote-controlled mechanisms, obviating the need for external fixation. Motorized intramedullary nails allow accurate, well-controlled distraction, and early clinical results have been positive.

Distraction osteogenesis.

James Sidman, MD, and Sherard A. Tatum, MD, address the following questions for discussion and debate. Is neonatal distraction osteogenesis (DO) better than lip-tongue adhesion or tracheotomy for micrognathic airway compromise? What role does DO have in adult orthognathic surgery situations? In monobloc and Le Fort III procedures, are internal or external devices preferable? What role does DO play in craniofacial microsomia? Is endoscopic DO better than open procedures for synostosis management? How has your technique changed or evolved over the past 5 years and what has doing this technique taught you?

Escoliosis de aparición precoz. ¿Qué opciones tengo? / Early onset scoliosis. What are the options?

El pronóstico de los ni˜nos con escoliosis de aparición precoz progresiva ha mejorado considerablemente gracias a los recientes avances en las técnicas quirúrgicas y no quirúrgicas, y al reconocimiento de la trascendencia de preservar la cavidad torácica. La mejora de técnicas ya existentes y el desarrollo de otras nuevas han modificado sustancialmente el tratamiento de esta entidad. Los yesos derrotatorios pueden indicarse en ni˜nos con curvas < 60◦ y progresión constatada, a los que no se ha realizado tratamiento quirúrgico previo. Tanto los tallos de crecimiento únicos como dobles son eficaces, aunque los últimos parecen ofrecer un mejor resultado. Los sistemas híbridos se plantean como mejor opción en ni˜nos que requieren un anclaje proximal con un perfil bajo. El vertical expandable prosthetic titanium rib (VEPTR®) puede ser útil en pacientes que presentan escoliosis congénita con fusiones costales y síndrome de insuficiencia torácica asociado. Los ni˜nos no tributarios de elongaciones repetidas por sus comorbilidades pueden ser candidatos a una técnica de Shilla o trolley de Luque. La modulación del crecimiento utilizando grapas de memoria o tirantes resulta prometedora en curvas menores, aunque se requieren más trabajos para definir su indicación precisa (AU)

The prognosis of children with progressive early onset scoliosis has improved considerably due to recent advances in surgical and non-surgical techniques and the understanding of the importance of preserving the thoracic space. Improvements in existing techniques and development of new methods have considerably improved the management of this condition. Derotational casting can be considered in children with documented progression of a < 60◦ curve without previous surgical treatment. Both single and dual growing rods are effective, but the latter seem to offer better results. Hybrid constructs may be a better option in children who require a low-profile proximal anchor. The vertical expandable prosthetic titanium rib (VEPTR®) appears to be beneficial for patients with congenital scoliosis and fused ribs, and thoracic Insufficiency Syndrome. Children with medical comorbidities who may not tolerate repeated lengthenings should be considered for Shilla or Luque Trolley technique. Growth modulation using shape memory alloy staples or other tethers seem promising for mild curves, although more research is required to define their precise indications (AU)

Mandibular osteotomies and distraction osteogenesis: evolution and current advances.

IMPORTANCE: Although a number of mandibular and occlusal problems may be addressed by orthodontic treatment alone, dentofacial osteotomies are often needed to achieve desired functional or cosmetic results. With the increased popularity of mandibular distraction osteogenesis in recent years, the role of the facial plastic and reconstructive surgeon is crucial in the multidisciplinary care of patients with such problems. OBJECTIVE: To review the history and evolution of mandibular osteotomies and distraction osteogenesis and to discuss indications, advantages, disadvantages, and recent advances of these techniques. EVIDENCE REVIEW: Medline and PubMed searches without date limits, confined to publications in English, German, and French languages were used to search for terms mandibular advancement, mandibular osteotomy, orthognathic surgery, mandibular distraction osteogenesis, prognathism, and retrognathism in the respective languages. References not found on the sources noted were found in print form in the New York Medical College Library when needed. Particular techniques, as originally described or relating to mandibular osteotomies and mandibular distraction osteogenesis, were critically reviewed. FINDINGS: The goal of surgical mandibular modification procedures is to correct a variety of craniofacial abnormalities for both functional and aesthetic purposes. Multiple techniques of both mandibular osteotomy and distraction osteogenesis have been shown to be effective. Their effectiveness and utility is primarily determined by the specific craniofacial defect and desired outcome, as well as surgeon preference and patient compliance. CONCLUSIONS: While mandibular osteotomy has evolved tremendously, distraction osteogenesis continues to grow as a leading method of surgical correction for a variety of craniofacial defects. Current research shows significant strides in making distraction more effective and efficient to use for both the surgeon and the patient. With the growing popularity of these procedures, the up-to-date knowledge of the facial plastic and reconstructive surgeon in these advances is of utmost importance.

Cranium and midface distraction osteogenesis: current practices, controversies, and future applications.

BACKGROUND: The adaptation of distraction osteogenesis (DO) to the midface and cranium in the 1990s and the advancements that followed at the turn of the century resulted in a shift of paradigm in craniofacial surgery. Because skeletal advancement was not sudden anymore, but incremental, the monobloc advancement became safer to perform. Because bone was generated in the distraction gap, bone grafts were no longer needed, and younger patients could benefit from craniofacial advancement. Today, DO is the most powerful tool to simultaneously correct both exorbitism and the respiratory impairment of the faciocraniosynostosis, but practices vary greatly between teams. METHODS: Current practices, controversies, and near-term future applications will be outlined and discussed. RESULTS: Our current treatment strategy for faciocraniosynostosis is based on early intervention (<18 months of age) to prevent irreversible brain damage. In the first 6 months of life, infants with faciocraniosynostosis receive posterior vault decompression. We currently use posterior vault distraction, using 2 internal distractors. Around 18 months of age, a frontofacial monobloc advancement with DO is performed. It further decompresses the brain, improves respiratory function, and corrects exorbitism. Because we operate at such an early age, we favor internal over external distractors. In severe faciocraniosynostosis, when midface hypoplasia causes major exorbitism endangering the eye or causes respiratory distress requiring a tracheotomy, we do not hesitate to perform a frontofacial monobloc advancement with DO before the age of 18 months, reinforcing the frontozygomatic junction with a plate and placing a transzygomatic pin. The pin is then connected to a traction rope. We frequently use the external distractors, which allow precise control over the rotation of the maxilla and are well tolerated after 5 years of age. When midface hypoplasia is very severe, we combine external and internal distractors. CONCLUSIONS: The ongoing debate between proponents of internal versus external distractors or 1-stage versus 2-stage approach is based mostly on anecdotal data. Multicenter prospective studies are necessary to bring objective data to answer these questions.

[Improvement of maxillofacial bone distraction osteogenesis: future prospects]. / Potentialisation de la distraction ostéogénique maxillofaciale, voies d'avenir.

Distraction osteogenesis is a tissue engineering technique based on Ilizarov's study on long bones. McCarthy transposed it rapidly to facial bones. His results in cranial and maxillofacial surgery are good and reproducible. However, the current protocols are long and the devices used are bulky. Finding new devices and association with other tissue engineering techniques should improve distraction osteogenesis and the patient's comfort.

Technological advances in nontraditional orthodontics.

New technological advances have helped the orthodontic profession progress in traditional and surgical methods of treatment. The profession has seen transitions from traditional braces to self-ligating brackets, lingual braces, removable aligners, and more advanced technology, which have helped to address concerns that include but are not limited to better diagnostics, anchorage control, length of treatment, and esthetics. An increase in the number of adult patients seeking orthodontic treatment and the need for a timely efficient care will continue to drive technology and the use of cone beam computed tomography, miniscrews, piezocision, distraction osteogenesis, and bioengineering.

Distracción ósea: tratamiento de la apnea obstructiva en neonatos con micrognatia / Mandibular distraction: treatment of obstructive apnea in neonates with micrognathia

Las malformaciones craneofaciales (secuencia de Pierre Robin, síndrome de Threacher-Collins, síndrome de Nager, etc.) con frecuencia van asociadas a hipoplasia mandibular grave, que puede causar obstrucción de la vía aérea superior por retroposición de la base de la lengua dentro del espacio faríngeo posterior. La mayoría de los pacientes responden al tratamiento postural, en decúbito prono, puede ser necesario controlar la saturación de oxígeno, insertar un tubo nasofaríngeo e incluso intratraqueal. En casos más graves con pausas prolongadas y frecuentes de apnea, la traqueostomía puede ser necesaria, pero se asocia a una alta morbilidad y, ocasionalmente, mortalidad. En los últimos 2 años, en la Unidad Multidisciplinaria de Labio y Fisura Palatina del Hospital Virgen de las Nieves de Granada, se ha tratado a 4 niños con apnea obstructiva grave secundaria a hipoplasia mandibular grave mediante distracción mandibular osteogénica, y este procedimiento se ha mostrado eficaz en la resolución del problema. Ha evitado la traqueostomía y se ha elongado la mandíbula en el plazo de 3-4 semanas. En este tiempo han desaparecido los problemas respiratorios obstructivos, así como también de la deglución, y los resultados estéticos obtenidos han resultado excelentes y las complicaciones, por el momento, mínimas(AU)

Craniofacial malformations (Pierre-Robin sequence, Treacher-Collins syndrome, Nager syndrome, etc.) are frequently accompanied by severe mandibular hypoplasia, which can cause upper airway obstruction due to retroposition of the base of the tongue in the posterior pharyngeal space. The majority of patients respond to postural treatment in decubitus prono. It may be necessary to monitor oxygen saturation and insert a nasopharyngeal or even an endotracheal tube. Tracheostomy may be necessary in more serious cases with long and frequent apnea pauses, but it is associated with high morbidity and occasional mortality. In the last two years, four children with severe obstructive apnea secondary to mandibular hypoplasia were treated by means of "osteogenic mandibular distraction" in the multidisciplinary Cleft Palate Department of Virgin de las Nieves Hospital (Granada, Spain). This procedure effectively resolved the problem, making tracheostomy unnecessary and lengthening the jaw within 3-4 weeks; in this period, obstructive respiratory problems and swallowing difficulties disappeared. The aesthetic results were excellent and the complications so far have been minimal. Objective: To present the results of a patient series with several types of POP treated using the same approach and operation(AU)

Distraction osteogenesis for bone repair in the 21st century: lessons learned.

Bone regeneration obtained by distraction osteogenesis is influenced by a series of factors. These include factors that are related to the mechanical stability of the system of distraction (internal or external devices), and to factors directly depending on the biology of the bone tissue, such as the method of bone interruption (osteotomy), the delay and rhythm of distraction, the anatomical site of the osteotomy, and the histological characteristics of the bone requiring reconstruction. The stability of the system of bone fixation depends on the rigidity of the frame, the connexion of the apparatus to the bone (wires, pins) and the intrinsic stability of the segment (length and level of maturation of bone regenerate). The radiological characteristics of bone regeneration (hypo- or hypertrophy) lead to the adaptation of the rhythm of distraction. Following more than 28 years of experience of application of the Ilizarov method for bone reconstruction, the authors describe the technique of frame assembly and the methods of evaluation and treatment of the complications of new bone formation.

[Fixator with motion capacity and distraction arthrodiatasis in post-traumatic elbow stiffness]. / Bewegungsfixateur und Distraktionsarthroplastik zur Behandlung der posttraumatischen Ellenbogensteife.

Elbow stiffness may result from trauma, burns and head injuries. It is defined as a total range of motion of <100° with no relevant loss of forearm rotation. Of particular relevance is the flexion deficit. A detailed analysis regarding the development of the elbow stiffness is required together with an exact diagnosis in order to plan the surgical intervention. Closed distraction of the elbow joint as arthrodiatasis with an external fixator is described and evaluated. Adequate long-term results can be achieved with this technique, which reflects proper selection of patients as well as coordination between surgeon, aftercare and physiotherapist. Contraindications are poor compliance, poorly controlled diabetes mellitus, active hepatitis B and C infection, HIV infection and acute articular infection.

Retração rápida de caninos / Rapid canine retraction

INTRODUÇÃO: a retração rápida de caninos por distração do ligamento periodontal é uma técnica de movimentação dentária que permite o fechamento de espaço da extração de primeiros pré-molares em um intervalo de duas ou três semanas, proporcionando uma redução significativa no tempo do tratamento ortodôntico. OBJETIVO: apresentar modificações propostas na técnica cirúrgica original e no posicionamento dos distratores. CONCLUSÕES: a retração rápida de caninos é uma técnica que proporciona uma redução significativa no tempo de tratamento ortodôntico. A modificação na técnica cirúrgica proporcionou maior velocidade e segurança ao ato cirúrgico. O distrator posicionado por palatina, no mínimo, proporcionou a preservação da tábua óssea vestibular e evitou a vestibularização dos caninos.

INTRODUCTION: Rapid canine retraction through distraction of the periodontal ligament is a tooth movement technique that allows the closure of first premolar extraction space within a period of two to three weeks while providing significant reduction in orthodontic treatment time. OBJECTIVE: To propose changes in the original surgical technique and in the placement of distractors. CONCLUSIONS: Rapid canine retraction is a technique that provides significant reduction in orthodontic treatment time. Changes in the surgical technique provided greater speed and safety in surgery. As a minimum benefit, when positioned palatally, distractors helped to preserve the buccal bone plate and prevented canine proclination.