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20 Craniofacial Tissue Regeneration Through Distraction Osteogenesis
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bers and muscles, which are torn apart when
subjected to excessive distraction. Subsequent
reparation results in scarring of the torn area with
loss of important properties of the tissues
involved. For this reason, distraction therapy
must also consider the surrounding tissue, and
the frequency and length of the distraction steps
must be carefully weighed clinically [5].
Clinical Applications
In clinical application in the eld of oral and
maxillofacial surgery, distraction osteogenesis
offers good possibilities in the therapy of craniofacial deformities and other challenges of daily
practice. It can be used for the lengthening/
expansion of nearly all major bones of the skull.
Clinical Considerations
As with so many therapeutic options in craniofacial surgery, the involvement of a multidisciplinary treatment team is essential. In addition to
oral and maxillofacial surgery, orthodontics in
particular, but also other surrounding specialties
such as ophthalmology, otolaryngology, or neurosurgery, is relevant depending on the problem.
Planning Procedure
Since, in contrast to the otherwise usual direct
control of success, no nal control is possible
intraoperatively or, at the latest, directly postoperatively, the preoperative planning has a great
responsibility. Thus, the later distraction length
and direction must be planned exactly in advance.
Dental aspects must be considered, such as preand postdistraction orthodontics and the subsequent functional loading direction of the bone.
Thus, the design and location of the osteotomy
are chosen rst and the orientation of the distraction vector is selected [25, 26]. Distractions in the
mandible are also expected to have effects on the
temporomandibular joints, leading to structural
changes in the temporomandibular joint [27].
Planning should not be limited to the use of simple conventional radiographs but should be
adapted with the aid of three-dimensional slice
imaging. This also allows accurate preoperative
planning of the virtual osteotomy line and can
simulate the distraction process [28–30].
Distraction Systems
The choice of a suitable distraction instrument
must be decided individually in each case. The
indication, the patient’s age, the desired distraction length, and, above all, the number of vectors
(unidirectional versus multidirectional) play a
decisive role. Finally, the patient’s wishes should
be considered, which can be decisive for good
compliance.
In principle, there are internal and external
distractors, which are characterized analogously
to xateur interne and externe. While internal
distractors are invisible to the patient and hidden
under a protective layer of skin, the external distractor is worn openly and is connected to the relevant bone fragments via pins. This has
advantages and disadvantages inherent in the
procedure. Although an internally worn distractor provides higher patient satisfaction, it carries
a higher risk of complications during removal,
since complete exposure must be performed
again. However, the internal distractors are
smaller in size and can therefore usually only
perform a unidirectional distraction of up to
15mm. Larger and multidirectional distractions,
on the other hand, can be achieved very well with
external distractors. However, due to the pins
piercing the skin, they cause a small scar after the
treatment is completed [31]. However, an
increased susceptibility to infection due to the
pins has not been observed so far [32]. Recent
devices and studies present a continuous distraction method. This method has some advantages,
as bone regeneration is faster and the surrounding
soft tissue can also grow along more gently (for
review, see Hate etal. [33]).
Indications andSurgical Procedure
Distraction is routinely used in all major bones of
the face and skull. The most frequently applied
distraction procedures are present in the mandi-
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a
c
d
b
e
f
Fig. 20.4 Classic osteotomies of skull bones and application of distraction devices. Distraction can be performed
in nearly all anatomical sites of the facial and cranial
skull. (a) Le Fort III osteotomy, (b) Le Fort II osteotomy,
(c) high Le Fort I distraction, (d) bimaxillary distraction,
ble and maxilla, followed by distraction in the
craniofacial and skull area. Figure20.4 demonstrates the classic osteotomies of skull bones and
application of distraction devices.
Cranial Vault Distraction
In addition to the commonly used mandibular
and maxillary augmentation, distraction
osteogenesis can also be used to augment the cranial vault in patients with craniosynostosis. It
plays a major role especially in synostoses of one
to two cranial sutures and can provide good
results here. On the other hand, in the case of
multiple cranial sutures, a formal reshaping of
the complete cranial vault is more indicated.
(e) median distraction of both maxilla and mandibula, and
(f) alveolar process distraction. (a and b) are volumetric
reconstructions by CBCT, (c and d) are side views on
CBCT images, and (e and f) are panoramic tomographic
images
Nevertheless, distraction of the posterior
cranial vault is often used when intracranial
pressure increases are expected but frontocranial distraction is not possible. The advantage
of posterior distraction is that no anatomical
structures limit the expansion as is the case
with anterior distraction. Here, especially the
eyes represent a natural barrier against a large
distraction [34].
Mandibular Distraction
The application of distraction osteogenesis in
the craniofacial region is most often described
in cases of mandibular underdevelopment and
has the highest significance here. Three oste-
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267
otomy sites are possible depending on the
growth deficit:
• Symphysis
• Corpus
• Ramus
The median osteotomy in the region of the
symphysis is suitable in cases of massive crowding of the teeth for orthodontic reasons. Since no
guide structures are to be expected in this area, an
intraoral osteotomy with rotary instruments is the
method of choice here.
The vertical osteotomy in the corpus region
can be performed in the retromolar area or in the
dentate jaw section with protection of the inferior
alveolar nerve by carefully weakening the mandibular canal with oscillating instruments and
then splitting it completely with an osteotome.
The horizontal osteotomy on the ramus mandibulae should be performed above the vascular
nerve bundle so that the leading structures are
protected as best as possible.
The combination of the individual distractions
is also possible and can already be used in infancy
to prevent possible airway obstructions in the
case of extreme mandibular recession [13, 35].
Midface Distraction
They can be combined with each other—similar to mandibular distraction. Therefore, extraoral
appliances are often used here to also enable multidirectional distractions. As a rule, the surgical
access is also intraoral (even with high Le Fort
levels), while transfacial or coronal accesses are
uncommon [13, 37, 38].
Le Fort IOsteotomy
The maxillary osteotomy at the level of the Le
Fort I plane dates back to Axhausen [39]. Since
the blood supply to the maxilla is ensured from
the palatal side, a vestibular osteotomy of the
maxilla is performed and the maxilla is then
folded down with the so-called down fracture
procedure [40, 41]. Subsequently, the maxilla
together with the dental arch is free of tension
and mobilized so that repositioning can take
place [13].
Le Fort II Osteotomy
In contrast to Le Fort I and also Le Fort III osteotomies, Le Fort II osteotomies are performed
less frequently. The procedure can correct both
the occlusion and the nasal shape in one step
[11]. Accordingly, Le Fort II osteotomy is indicated for nasomaxillary hypoplasia. Osteotomy
is performed along the Le Fort II line, often using
a transconjunctival incision and intraoral vestibular incision in the maxilla nowadays [42, 43].
In contrast to mandibular distraction, midfacial
distraction often requires vectors that are composed of many small partial vectors. The osteotomy sites are found on different Le Fort levels
that are classied according to the French surgeon René Le Fort. The typical fracture lines discovered by him in the transverse direction above
the dentition can also be used for targeted osteotomies (and subsequent distractions). Three
standard patterns of midface fractures are identied [36]:
– Horizontal Le Fort I fracture
– Pyramidal Le Fort II fracture
– Transverse Le Fort III fracture
Le Fort III Osteotomy
The Le Fort III osteotomy represents a much
more invasive surgical therapeutic approach than
the Le Fort I- or Le Fort II-level osteotomies, so
this procedure is only performed in cases of pronounced midface recession. However, this is
especially true in pronounced syndromic conditions such as Apert or Crouzon syndrome.
Using a bicoronary incision, the orbitae are
rst exposed from the cranial side and the two
temporal fossae are exposed laterally up to the
zygomatic arch. The nasal bone is then osteotomized from the frontal bone, with the osteotomy
line extending over the medial orbital wall, the
orbital oor, the lateral orbital wall, and into the
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zygomaticofrontal suture. This is followed by the
osteotomy of the zygomatic arch and the separation of the maxilla from the pterygoid process as
in the Le Fort I osteotomy [13].
However, a major difculty with Le Fort III
osteotomy is also the subsequent advancement of
the midfacial complex, as there is a strong pull on
the surrounding soft tissues. Advancing more
than 10 mm is almost impossible. In this case,
distraction osteogenesis can make a very good
contribution to therapeutic success by gradually
growing the soft tissues along during distraction
[41, 44, 45].
Alveolar Process Distraction
With the proliferation of dental implants, it has
become increasingly important to maintain a sufciently large alveolar process as an implant site.
In addition to many bone replacement options,
vertical distraction osteogenesis offers an excellent way to enlarge the alveolar process and prepare it for subsequent implant placement. The
advantages over autologous bone substitutes
include the lack of morbidity at the bone harvest
site. Allogeneic bone replacement approaches
have the disadvantage of permanently implanting
foreign-body material with the risk of infection
or immunological reaction. These problems are
not present with alveolar process distraction, as
autologous bone formation occurs. Another indication is for ankylosed teeth that would not reach
the occlusal plane naturally.
A segmental osteotomy of the alveolar processes is surgically performed. The bone fragments are provided with extraosseous,
intraosseous, and dental anchored distractors.
The crestal bone fragment should remain pedicled over the periosteum and mucosa at the vascular supply. Care should be taken to minimize
denudation of the alveolar process bone.
Therefore, it is recommended that the incision be
made from paracrestal to as far into the vestibulum as possible. After sufcient distraction, the
distractor removal can be performed simultaneously with the implantation.
The alveolar process distraction remains technically difcult to perform. Some conditions
must be met to ensure a good surgical outcome.
For example, a minimum height of the crestal
element of 8mm is necessary. Furthermore, the
predictability in the maxilla is limited by the fact
that the less extensible mucosal pedicle leads to
palatal deviations (for review, see ToledanoSerrabona, Sánchez-Garcés [46], and Zhao and
Wang [13, 47]).
Distraction Healing
The distraction healing follows the osteotomy.
This period can be clinically subdivided into a
latency period, a distraction period, and a consolidation period.
During the consolidation period, it is possible
to apply external stimuli to accelerate the regenerate tissue. Callus molding is a term that
describes the possibility to alter the position of
the bone fragments in a dened manner according to the application of external forces (e.g., the
use of elastics in combination with a concomitant
orthodontic treatment). Distractor removal can be
done at two different time points: (1) after a complete bony regenerate healing or (2) earlier during the consolidation phase, but in the latter
situation, bone fragments have to be xed by
osteosynthesis plates to allow the regenerate tissue to completely mineralize.
Distraction healing follows the osteotomy.
This period can be divided clinically into a
latency period, a distraction period, and a consolidation period. During the consolidation
period, it is possible to apply external stimuli to
accelerate the regenerating tissue. Callus molding is a term used to describe the possibility of
changing the position of bone fragments in a
dened manner according to the application of
external forces (e.g., the use of elastics in combination with concomitant orthodontic treatment). The distractor can be removed at two
different times: (1) after complete healing of the
bone regenerate or (2) at an earlier stage during
the consolidation phase, in which the bone frag-
20 Craniofacial Tissue Regeneration Through Distraction Osteogenesis
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269
ments must be xed by osteosynthesis plates to
allow the regenerated tissue to mineralize completely [48].
Various procedures have already been established to reduce the duration of bone repair during distraction osteogenesis. Various nonsurgical
measures such as electromagnetic stimulation,
use of growth factors, and application of ultrasound can inuence and in some cases accelerate
bone regeneration (for review, see Fatima and
Jeelani [49] and Meyer and Kleinheinz [1]).
Distraction Protocol
The distraction protocol must be individually
adapted to each patient and the situation at hand.
Accordingly, in older patients, a longer time for
distraction must be followed to obtain the best
hard and soft tissue response. Nevertheless, distraction osteogenesis can in principle be performed at any age. However, the present situation
must also be evaluated. Larger hard or soft tissue
deciencies require a longer latency period until
the healing process begins. The greater the
desired distraction distance, the longer the subsequent consolidation time must be planned.
Rate ofDistraction
The inventor of classical distraction osteogenesis,
G.A. Ilizarov, initially postulated a distraction rate
of 1mm per day to create optimal conditions for
distraction osteogenesis [6]. This daily distraction
succeeds in aligning the collagen bers in parallel
and also orienting the other cells in this growth
direction. Larger distraction distances run the risk
of creating microtrauma and tearing the newly
formed vessels and cells. The healing process is
thus interrupted and starts anew. Depending on the
trauma, however, the therapy may also be completely interrupted, in that a pseudarthrosis forms
and there is no longer a bony union of the two
bone fragments. Furthermore, collateral damage
must be taken into account, as long distractions
also lead to soft tissue damage, especially to muscles and nerves [5, 50, 52].
Meyer and Wiesmann [48] have shown that
lower strains result in improved cross-linking of
collagen bers, while greater strain distances
tend to result in molecular sliding within the
brils. As a result, a sufcient brillar structure
cannot develop and the tissue is not stable.
Furthermore, it could be shown that at high shear
stress on the bone fragments by strong distraction, the osteoblasts die apoptotically [27].
Latency Period
During the latency period, granulation tissue
initially develops starting from the blood clot. In
the further course, the tissue becomes increasingly brous due to collagen synthesis.
Angiogenesis causes many capillaries to sprout,
thereby promoting orderly vascularization.
Immigration of mesenchymal stem cells occurs
from the bone marrow and surrounding periosteum. The exact duration of this latency period
is scientically controversial and not clearly
established [12, 50, 51].
Distraction Period
The distraction phase usually lasts about 10days,
with constant traction strongly inuencing the
regeneration process. The dynamic microenvironment creates a tissue parallel to the distraction
vector. Furthermore, angiogenesis is increased,
and broblast-like cells proliferate [12, 15, 50].
Consolidation Period
After the distraction has taken place, the consolidation phase follows. Here, the fragments are rigidly
xed together in their nal position until the two
bone fragments are bony consilidated. It is irrelevant whether the xation is performed with the
already used distractor (passive) or with newly
applied osteosynthesis screws or plates. Although
the application of new osteosynthesis material
involves a new procedure, it offers the patient more
comfort than the often larger distraction device.
The consolidation phase depends, among
other things, on the distraction distance and
patient-specic factors such as age. Therefore,
the period usually varies between 6 and 12weeks.
During this time, the callus mineralizes. In longterm posttreatment, distractions regularly appear
solid, and recurrences are rare (Fig. 20.5). The
distracted tissue can be used for placing implants
in the jaw region (Fig.20.6), since the quality of
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a
a
a
a
b
b
b
b
a
a
Fig. 20.5 Distraction healing in a patient with an extreme
chin distraction displays the gradual biological process
from an initial non-mineralized precursor tissue to a fully
mineralized bone. The shape of the tissue resembles the
b
b
normal anatomical phenotype of the elongated bone. The
tissue is stable over time. (a) Side views based on CBCT,
(b) panoramic views based on CBCT
a
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b
c
d
e
g
f
h
i
Fig. 20.6 Implants can be placed in the regenerated bone, since the quality of the bone site is equal to the original bone.
(a) Side view preoperatively based on CBCT, (b) lateral view postoperatively based on CBCT, (c) panoramic view
postoperatively based on CBCT, (d) lateral view after distraction based on CBCT, (e) and (f) panoramic views, (g) axial
stratication based on CBCT after distraction and before implantation, (h) panoramic view after the dental implants, (i)
clinical ndings after distraction and placement of the dental implants
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the bone is similar to the original bone at the distraction site [1, 26, 34, 51].
Follow-Up
In the follow-up during distraction, besides clinical parameters, imaging techniques are important
and indispensable to estimate the stage of ossication. Both sonographic and radiological means
are available for this purpose, each of which permits its own possible conclusions.
Sonographic Control
In the head and neck region, sonography allows
the soft tissue and the fracture gap to be adequately diagnosed [53–55]. Sonographic diagnostics (B-mode) allow conclusions to be drawn
about the tissue based on echogenicity. An inhomogeneous echo recipient reection pattern corresponds to a connective tissue (collagen) rich in
bers in the distraction gap. In the further course
of distraction osteogenesis, the rst bone columns develop, which can be recognized by
impact echoes with complete distal sound extinction. After distraction is complete, the distraction
gap continues to consolidate as the connective
tissue becomes denser and further mineralization
processes harden the bone. This is shown by an
increase in further sound-remitting sites [53].
During active distraction, sonography is superior to radiology. Due to the low mineralization,
the distraction gap appears radiologically empty,
while sonography allows very good observation
of the individual phases of the soft tissue callus.
However, a certain minimum width of the bone
and distraction gap is required for this. Therefore,
due to the very thin bone walls, sonography is
often insufcient for midface distractions. On the
other hand, even small ossication nuclei can be
detected at an early stage and the distraction distance achieved can be accurately visualized. The
procedure thus allows very good progress ndings in the mandible.
However, since the transition between the
bone fragments and the distraction gap
becomes increasingly blurred, a radiological
examination is indispensable for nal assessment [13, 56, 57].
Radiological Control
Radiological reporting of distraction osteogenesis is important, especially at the conclusion of
distraction treatment, to clearly document consolidation. Just as sonographic ndings in the
midface are difcult, so are conventional radiological ndings. However, good detections can
be made by modern high-resolution CTs or
CBCTs, in which even the smallest bone fragments can be visualized [58]. With the highest
resolution, even small ossication centers can be
made visible. However, due to poorer availability
and radiation exposure, this procedure cannot be
performed on a regular basis, but should only be
performed at the end of the treatment shortly
before distractor removal [13, 59, 60].
Future Perspective
Since the rst description of distraction osteogenesis by G.A. Ilizarov, countless methods have
been established in various disciplines and are
still in use today [61]. Many animal experimental
and clinical studies have been performed [62–
64]. Nevertheless, this method remains techni-
cally challenging because the mechanisms of
bone maturation in the distraction gap as well as
the long-term behavior after distraction are not
yet fully understood. Continuous distraction procedures have been tested for many years and have
already shown clear advantages in animal experiments. However, the leap into clinical application
has not yet taken place. In addition, other augmentative procedures have become established in
recent years, such as PEEK bone implants [65–
67]. They allow augmentation with minimal sur-
gical risk, without a lengthy distraction phase,
and the success of which can be determined
directly postoperatively [68]. However, this new
procedure should not be seen as a replacement
for the distraction osteogenesis that has been
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performed for decades, but rather as an extension
of the therapeutic toolbox.
Conclusion
Bone tissue is the only tissue in the human body
that offers the opportunity to produce its own tissue without scarring (restitutio ad integrum).
This can be exploited very well therapeutically as
distraction osteogenesis to regenerate larger section defects. If the conditions for sufcient distraction are met, this therapeutic procedure offers
an excellent option for augmenting bone and surrounding soft tissue in mandibular growth decits as well as in syndromic malformations of the
midface. The advantages of distraction osteogenesis are manifold. It can be performed during
growth, which is not possible with other therapeutic measures. In addition, it can be used early
in syndromic patients to prevent typical comorbidities such as respiratory difculties, lack of
speech development, and swallowing disorders.
Novel procedures such as PEEK bone augmentation do not replace this procedure, which has
been tried and tested for many decades, but
extend it. Thus, distraction osteogenesis remains
an established but also promising surgical method
in the treatment of congenital and acquired craniofacial malformations.
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