Distraction Osteogenesis of the Maxilla

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Distraction osteogenesis is a surgical technique for reconstruction of bony deformities. Increased amounts of both bone and soft tissue are created as a result of the gradual displacement of surgically created bony fractures. Because distraction techniques generate new bone, the morbidity of harvesting bone from other sites is obviated. ^{[1, 2]}

In terms of techniques, traditional advancement of the mid face with osteotomies and harvesting of bone grafts are associated with high rates of midface regression and morbidity. Distraction in the mid face decreases intraoperative morbidity and rates of postoperative midface regression. Both of these factors have led to an increase in the popularity of midface distraction, demonstrated in a survey of craniofacial surgeons, who reported that the mid face was the site of distraction in 28% of their cases.

Views of a person with Apert syndrome are below.

Osteogenic distraction is the result of the evolution of techniques for bone fixation, skeletal traction, and osteotomy. Osteogenic distraction was first used in orthopedics to lengthen bones after planned osteotomies. However, the complication rate remained high and the technique was not understood until Gavriel Ilizarov, a Russian orthopedic surgeon, performed detailed studies in 1952. Working in a rural clinic in Siberia, Ilizarov did not have the requisite equipment for surgeons used at that time. Therefore, he performed studies by using his own equipment and procedures, which proved to be more effective than contemporary procedures, as evidenced by modern day use of his methods.

Distraction of the maxilla was first performed by expanding the midpalatal suture in monkeys in 1965. The first human application of maxillary distraction in craniofacial surgery was a mandible distraction in 1989. Case reports of its application in maxillary distraction were published in 1992.

The principle of distraction osteogenesis is based on new bone formation that develops when tension forces are applied. This new bone formation is a result of membranous ossification.

The viability of bone cells (osteocytes and osteoblasts) is crucial in distraction osteogenesis. Bone viability can be enhanced by limiting damage to the cortex by making distinct cuts. Bone viability can also be enhanced by preserving the blood supply to the bone, which is necessary for its growth, by leaving adequate soft tissue coverage. Endothelial cells may stimulate angiogenesis and play an important role as well.

Distraction histogenesis is a term that describes the gradual increase in soft tissue volume in response to the stress forces applied with bony distraction. Traditional midface techniques provide immediate bony correction but do not allow for compensatory growth of the soft tissues. As a result of scarring and memory, the soft tissue often contracts to its preoperative state. This is thought to be the main reason for the high rate of relapse of midface insufficiency after the use of traditional techniques. In contrast, distraction techniques create a gradual increase in the amount of soft tissue by preventing its contraction.

Indications for distraction osteogenesis of the maxilla are craniofacial anomalies, facial clefts, severe sleep apnea, hemifacial microsomia, a deficient alveolar ridge, and complex trauma.

Craniofacial anomalies account for most indications for maxillary distraction. Distraction may improve aesthetic contouring of the face, resolve sleep apnea, and improve orthognathics. Distraction can be applied to a wide variety of anomalies with maxillary deficiency; Crouzon syndrome and Pfeiffer syndrome account for most of the reported cases. Advancement of the lower maxilla, as in a Le Fort I osteotomy, or complete midfacial advancement, as in a Le Fort III procedure, can be accomplished. ^[3] Distraction cannot only achieve the aesthetic goals of realignment but also apnea resolves, obviating tracheostomy.

Patients with facial clefting often have maxillary hypoplasia. Even after cleft repair and orthodontic treatment, severe maxillary deficiency may persist. These patients traditionally undergo repair with Le Fort I osteotomy advancement with internal fixation. This approach often fails because of palatal scarring, soft tissue memory, and scar formation. External distraction leads to slow expansion of the surrounding tissues, allowing the body to accommodate the new position of the maxilla. Krimmel et al found that external distraction is superior to traditional techniques in patients who have facial clefting with maxillary hypoplasia. ^{[4, 5, 6]}

Sleep apnea in select adults with a deficiency in their upper airway dimension may be an indication for distraction.

Hemifacial microsomia may respond to a combination of maxillomandibular distraction. Satoh et al found that distraction osteogenesis is a safe and effective method for reducing the use of orthodontic appliances to 7-14 years. ^[7]

A deficient alveolar ridge is another indication for maxillary distraction. A deficiency of the alveolar ridge may be the result of circumstances, such as traumatic avulsion of mandibular incisor teeth or a congenital deformity. Expansion of the alveolar housing creates a site for the placement of a dental implant. This may improve ridge aesthetics for a pontic, or replacement, artificial tooth or teeth that are mounted on a fixed or removable dental appliance, and it may expand the alveolus to allow for orthodontic tooth movement.

Distraction may also be indicated in cases of complex, high-impact midface fractures, especially for the delayed repair of bony fractures of the mid face.

The maxilla (see the image below) has several roles. It houses the teeth, forms the roof of the oral cavity, forms the floor of and contributes to the lateral wall and roof of the nasal cavity, houses the maxillary sinus, and contributes to the inferior rim and floor of the orbit. Two maxillary bones are joined in the midline to form the middle third of the face.

In the midline of the anterior surface of the maxilla is found a prominence, called the anterior nasal spine, with a lateral concave rim, called the nasal notch, that forms the floor of the piriform aperture. Inferiorly, the alveolar process of the maxilla houses the teeth, including central incisors, lateral incisors, canines, 2 premolars, and 3 molars in adults. The tooth roots form vertical, wavelike eminences in the anterior face of the maxilla; the canine root is the most prominent. The canine root forms a vertical ridge, termed the canine eminence, in the anterior face of the maxilla. The shallow fossae medial and lateral to the canine eminence are called the incisive fossa and the canine fossa, respectively.

For more information about the relevant anatomy, see Facial Bone Anatomy.

As long as the bone where the distraction device is placed is adequate, the procedure has few contraindications. Young patients must be selected carefully because of their fragile bones and because the amount of bone available for device placement may be inadequate. In infants, numerous studies have demonstrated successful results with the careful selection of infants, with no untoward effects. The surgeon must preoperatively confirm that the strength of the transport and anchorage segments is adequate to withstand forces of mobilization and transport.

Skeletal deformities resulting from bone disease are not a contraindication, as long as enough bone for distraction is available.

Last, the patient’s participation is as important as the procedure itself. A noncompliant patient can cause any distraction procedure to fail.

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Perez D, Ellis E 3rd, Vega OA. Distraction osteogenesis for craniomaxillofacial problems. Tex Dent J. 2011 Nov. 128(11):1159-70. [Medline].

Patel PA, Warren SM, McCarthy JG. Maxillary mucocele with proptosis and visual impairment: a late complication of Le Fort III distraction. J Craniofac Surg. 2013 Nov. 24(6):2000-2. [Medline].

Krimmel M, Cornelius CP, Roser M, Bacher M, Reinert S. External distraction of the maxilla in patients with craniofacial dysplasia. J Craniofac Surg. 2001 Sep. 12(5):458-63. [Medline].

Rao Janardhan S, Kotrashetti SM, Lingaraj JB, Pinto PX, Keluskar KM, Jain S, et al. Anterior Segmental Distraction Osteogenesis in the Hypoplastic Cleft Maxilla: Report of five cases. Sultan Qaboos Univ Med J. 2013 Aug. 13(3):454-9. [Medline]. [Full Text].

Lucchese A, Gherlone EF, Asperio P, Baena RR. The distraction osteogenesis in midfacial hypoplasia. J Craniofac Surg. 2014 May. 25(3):831-4. [Medline].

Satoh K, Suzuki H, Uemura T, Hosaka Y. Maxillo-mandibular distraction osteogenesis for hemifacial microsomia in children. Ann Plast Surg. 2002 Dec. 49(6):572-8; discussion 578-9. [Medline].

Guyette TW, Polley JW, Figueroa A, Smith BE. Changes in speech following maxillary distraction osteogenesis. Cleft Palate Craniofac J. 2001 May. 38(3):199-205. [Medline].

Harada K, Baba Y, Ohyama K, Omura K. Soft tissue profile changes of the midface in patients with cleft lip and palate following maxillary distraction osteogenesis: a preliminary study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Dec. 94(6):673-7. [Medline].

Krimmel M, Cornelius CP, Bacher M, Gülicher D, Reinert S. Longitudinal cephalometric analysis after maxillary distraction osteogenesis. J Craniofac Surg. 2005 Jul. 16(4):683-8. [Medline].

Wong GB, Padwa BL. LeFort I soft tissue distraction: a hybrid technique. J Craniofac Surg. 2002 Jul. 13(4):572-6; discussion 577. [Medline].

Tan W, Yu B, Niu F, Gui L. Changes in width of lower face after unilateral mandibular distraction osteogenesis. J Craniofac Surg. 2012 Jan. 23(1):94-7. [Medline].

Iannetti G, Fadda T, Agrillo A, Poladas G, Iannetti G, Filiaci F. LeFort III advancement with and without osteogenesis distraction. J Craniofac Surg. 2006 May. 17(3):536-43. [Medline].

Koudstaal MJ, Smeets JB, Kleinrensink GJ, Schulten AJ, van der Wal KG. Relapse and stability of surgically assisted rapid maxillary expansion: an anatomic biomechanical study. J Oral Maxillofac Surg. 2009 Jan. 67(1):10-4. [Medline].

Cohen SR. Midface distraction. Semin Orthod. 1999 Mar. 5(1):52-8. [Medline].

Fan H, Wang X, Lin Y, Zhou Y, Yi B, Li Z. [Application of distraction osteogenesis in severe maxillary hypoplasia secondary to cleft palate]. Zhonghua Yi Xue Za Zhi. 2002 May 25. 82(10):699-702. [Medline].

Ghysen D, Ozsarlak O, van den Hauwe L, et al. Maxillo-facial trauma. JBR-BTR. 2000 Aug. 83(4):181-92. [Medline].

Harada K, Ishii Y, Ishii M, Imaizumi H, Mibu M, Omura K. Effect of maxillary distraction osteogenesis on velopharyngeal function: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 May. 93(5):538-43. [Medline].

Harada K, Sato M, Omura K. Long-term skeletal and dental changes in patients with cleft lip and palate after maxillary distraction: a report of three cases treated with a rigid external distraction device. Cranio. 2005 Apr. 23(2):152-7. [Medline].

Hierl T, Klöppel R, Hemprich A. Midfacial distraction osteogenesis without major osteotomies: a report on the first clinical application. Plast Reconstr Surg. 2001 Nov. 108(6):1667-72. [Medline].

Kessler P, Wiltfang J, Schultze-Mosgau S, Hirschfelder U, Neukam FW. Distraction osteogenesis of the maxilla and midface using a subcutaneous device: report of four cases. Br J Oral Maxillofac Surg. 2001 Feb. 39(1):13-21. [Medline].

Ko EW, Figueroa AA, Guyette TW, Polley JW, Law WR. Velopharyngeal changes after maxillary advancement in cleft patients with distraction osteogenesis using a rigid external distraction device: a 1-year cephalometric follow-up. J Craniofac Surg. 1999 Jul. 10(4):312-20; discussion 321-2. [Medline].

Li KK, Powell NB, Riley RW, Guilleminault C. Distraction osteogenesis in adult obstructive sleep apnea surgery: a preliminary report. J Oral Maxillofac Surg. 2002 Jan. 60(1):6-10. [Medline].

Matsumoto K, Nakanishi H, Koizumi Y, et al. Segmental distraction of the midface in a patient with Crouzon syndrome. J Craniofac Surg. 2002 Mar. 13(2):273-8. [Medline].

Meling TR, Tveten S, Due-Tonnessen BJ, Skjelbred P, Helseth E. Monobloc and midface distraction osteogenesis in pediatric patients with severe syndromal craniosynostosis. Pediatr Neurosurg. 2000 Aug. 33(2):89-94. [Medline].

Morovic CG, Monasterio L. Distraction osteogenesis for obstructive apneas in patients with congenital craniofacial malformations. Plast Reconstr Surg. 2000 Jun. 105(7):2324-30. [Medline].

Papageorge MB. Distraction osteogenesis for augmentation of the deficient alveolar ridge. J Mass Dent Soc. 2002 Spring. 51(1):24-30, 51. [Medline].

Polley JW, Figueroa AA. Maxillary distraction osteogenesis with rigid external distraction. Atlas Oral Maxillofac Surg Clin North Am. 1999 Mar. 7(1):15-28. [Medline].

Rachmiel A, Jackson IT, Potparic Z, Laufer D. Midface advancement in sheep by gradual distraction: a 1-year follow-up study. J Oral Maxillofac Surg. 1995 May. 53(5):525-9. [Medline].

Swennen G, Dempf R, Schliephake H. Cranio-facial distraction osteogenesis: a review of the literature. Part II: Experimental studies. Int J Oral Maxillofac Surg. 2002 Apr. 31(2):123-35. [Medline].

Swennen G, Schliephake H, Dempf R, Schierle H, Malevez C. Craniofacial distraction osteogenesis: a review of the literature: Part 1: clinical studies. Int J Oral Maxillofac Surg. 2001 Apr. 30(2):89-103. [Medline].

Uemura T, Hayashi T, Satoh K, et al. A case of improved obstructive sleep apnea by distraction osteogenesis for midface hypoplasia of an infantile Crouzon’s syndrome. J Craniofac Surg. 2001 Jan. 12(1):73-7. [Medline].

Anil R Shah, MD Plastic Surgeon, Private Practice

Anil R Shah, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, Triological Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: inmode.

Daniel G Danahey, MD, PhD Consulting Staff, Department of Otolaryngology, DuPage Medical Group

Daniel G Danahey, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Cleft Palate-Craniofacial Association, American Academy of Otolaryngology-Head and Neck Surgery, Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert M Kellman, MD Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, American Rhinologic Society, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Mimi S Kokoska, MD Physician, Department of Otolaryngology-Head and Neck Surgery, Aurora Health Care

Mimi S Kokoska, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American College of Surgeons, American Head and Neck Society

Disclosure: Nothing to disclose.

Distraction Osteogenesis of the Maxilla

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