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Distraction osteogenesis /certified fixed orthodontic courses by Indian dental academy
1. DISTRACTION OSTEOGENESIS – A
FAREWELL TO MAJOR OSTEOTOMIES ?
--- Dr. Chetan Jayade
Asst. Professor
Department of Orthodontics
S.D.M. College of Dental Sciences
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2. DISTRACTION OSTEOGENESIS – A
FAREWELL TO MAJOR OSTEOTOMIES ?
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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3. The treatment of craniofacial deformities
poses a great challenge to the
Orthodontist and the Oral Surgeon alike.
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9. DISTRACTION OSTEOGENESIS
Steps involved :
a) Corticotomy/Osteotomy
b) Latency period
Rate
c) Distraction phase
Rhythm
d) Consolidation phase
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11. DISTRACTION OSTEOGENESIS
Steps involved :
a) Corticotomy/Osteotomy : A low energy
osteotomy of the cortex preserving the
local blood supply to both the cortex and
the medullary canal.
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12. DISTRACTION OSTEOGENESIS
Steps involved :
b) Latency period : The time following the
osteotomy when initial fracture healing
bridges the cut bone prior to initiating the
distraction.
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13. DISTRACTION OSTEOGENESIS
Steps involved :
c) Distraction phase :
i) Rate – the number of millimeters/day at
which the bone surfaces are stretched.
ii) Rhythm – The number of incremental
distractions per day.
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14. DISTRACTION OSTEOGENESIS
Steps involved :
d) Consolidation phase : The time following
distraction, for which the device is stabilized.
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15. DISTRACTION HISTOGENESIS
The sequence of adaptive changes in the soft
tissues, adjacent to the distracted segments.
Healing Index: The number of days or months
from the surgery to full, unprotected load
bearing for each centimeter of bone length.
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20. DISTRACTION OSTEOGENESIS
HISTORICAL PERSPECTIVE
Problems with the earlier attempts:
a) Lack of control of the bone segments
b) Inadequacy of the appliances
c) Instability of fixation and complications
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23. DISTRACTION OSTEOGENESIS
HISTORICAL PERSPECTIVE
ILIZAROV’S TECHNIQUE
Foundations laid via rigorous experimentation
a) Dog experiments (Long bones)– 7 groups
•
Group I,II and III differed in the type of fixation
•
Group IV and V in the amount of marrow
•
Group VI and VII
distraction
underwent transverse
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24. DISTRACTION OSTEOGENESIS
HISTORICAL PERSPECTIVE
ILIZAROV’S TECHNIQUE
Foundations laid via rigorous experimentation
b) Dog experiments (Membrane bones)
Distraction results were similar to that seen in the
long bones.
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28. DISTRACTION OSTEOGENESIS
ILIZAROV’S CRITERIA
a) Surgical procedure must involve minimum
marrow; hence, corticotomy preferred.
b) Fixity of the device: Rigid fixation is a must.
c) Rate: Optimal to be 1 mm per day
d) Rhythm: Optimum of 2-4 activations/day
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29. DISTRACTION OSTEOGENESIS
THE TENSION-STRESS EFFECT
The histologic evidences of Ilizarov’s work form
the basis of distraction procedures in any part
of the body.
These histologic findings were coined by Ilizarov
as the ‘Tension-Stress’ effect.
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31. DISTRACTION OSTEOGENESIS
HISTORICAL PERSPECTIVE
SNYDER (1972,73) resected a dog mandible and
performed distraction successfully.
10 week healing period followed by distraction
of 1mm/day for 14 days.
MICHELLI and MIOTI (1977) and PANIKAROVSKI
(1982)carried out modified experiments in the
canine mandibles
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33. DISTRACTION OSTEOGENESIS
HISTORICAL PERSPECTIVE
4 children with craniofacial anomalies
subjected to a distraction protocol of
three weeks followed by a 8-10
consolidation.
were
upto
week
Long-term studies of the same patients indicate a
successful result.
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34. DISTRACTION OSTEOGENESIS
HISTORICAL PERSPECTIVE
MOLINA and ORTIZ MONASTERIO(1995) used bidirectional appliances
Mc’CARTHY
demonstrated the efficacy of a
mulitdirectional appliance.
GUERRERO (1990) used an intra-oral appliance to
widen mandibular arches.
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39. DISTRACTION OSTEOGENESIS
A BIRD’S EYE-VIEW THE ORIGINS AND
EVOLUTION OF DO IN THE CRANIOFACIAL
REGION
a) Phase of traction without surgery
b) Upsurge in limb-lengthening procedures
c) Progression from Extra-oral Unidirectional to
Extra-oral Multidirectional distraction.
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40. DISTRACTION OSTEOGENESIS
A BIRD EYE-VIEW THE ORIGINS AND
EVOLUTION OF DO IN THE CRANIOFACIAL
REGION
d) Progression from extra-oral to intraoral devices
e) Progression from manual devices to motorized
devices
f) Progression from the removable fixators to
biodegradable fixators
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41. DISTRACTION OSTEOGENESIS
CURRENT SCOPE OF DO
Correction of Maxillo-Mandibular deformities
a) Maxillary lengthening
b) Mandibular lengthening
c) Maxillary and Mandibular widening
d) Lengthening of the Hard palate
e) Distraction in other cranio-facial areas.
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42. DISTRACTION OSTEOGENESIS
CURRENT SCOPE OF DO
Alveolar ridge augmentation
Transport
disc
osteogenesis.
and
Dental Distraction.
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Transformation
44. DISTRACTION OSTEOGENESIS
TRANSFORMATION OSTEOGENESIS
The conversion of non-osseous interpositions
into normal bone by combined compression
and traction forces, sometimes augmented by
a nearby corticotomy.
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45. DISTRACTION OSTEOGENESIS
BONE TRANSPORTATION
The regeneration of intercalary bone defects by
combined distraction and transformation
osteogenesis.
i.
Bifocal transportation
ii. Trifocal transportation
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48. DISTRACTION OSTEOGENESIS
TISSUE CHANGES FOLLOWING DO
a.
Skeletal changes – Formation of Regenerate
b.
Soft
tissue
adaptations
Histogenesis
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–
Distraction
49. DISTRACTION OSTEOGENESIS
TISSUE CHANGES FOLLOWING DO
HISTOLOGIC CHANGES
•
During latency phase – formation of a fibrous
bridge.
•
During distraction phase – distinct zones seen
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50. DISTRACTION OSTEOGENESIS
TISSUE CHANGES FOLLOWING DO
BIOCHEMICAL FEATURES OF REGENERATE
•
Increased levels of alkaline phosphate, pyruvic
acid.
•
TGF-
Beta
1
levels
increase
upto
the
consolidation phase; Osteocalcin after the
consolidation phase.
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51. DISTRACTION OSTEOGENESIS
TISSUE CHANGES FOLLOWING DO
DISTRACTION HISTOGENESIS
Sinusoidal
•
Neovascularization
•
Neomyogenesis
Transport
Atrophy seen is transient
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52. DISTRACTION OSTEOGENESIS
TISSUE CHANGES FOLLOWING DO
DISTRACTION HISTOGENESIS
•
Nerve growth as during embryogenesis was
reported by Ilizarov.
•
However, studies by Block and Ippolito have
shown mild nerve injury due to stretching
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53. DISTRACTION OSTEOGENESIS
TISSUE CHANGES FOLLOWING DO
DISTRACTION HISTOGENESIS
•
Mild pathoogic changes have been reported on
the TMJ by a few authors like Mc’Carthy.
These are again reversible with time
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56. DISTRACTION OSTEOGENESIS
FACTORS AFFECTING DO
BIOLOGIC FACTORS
•
Increased micromotion by increasing rhythm
causes
increased
vasculogenesis
and
enzymes and decreases the tissue damage and
the degenerative changes
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57. DISTRACTION OSTEOGENESIS
FACTORS AFFECTING DO
CONSOLIDATION PHASE
Assessment of new bone is by:
I. Plain radiography
ii. Quantitaive Computed Tomography (QCT)
iii. Ultrasonography
iv. Dual energy X-ray absorptimetry
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59. DISTRACTION OSTEOGENESIS
FACTORS AFFECTING DO
CONSOLIDATION PHASE
Clinical assessment of consolidation
•
Distraction Consolidation index
This however, is applicable to the long bones.
•
6-8 weeks optimal in the craniofacial region
– SACHDEVA, COPE (1999,2000)
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60. DISTRACTION OSTEOGENESIS
FACTORS AFFECTING DO
BIOMECHANICAL FACTORS
•
Planning the distraction vector
•
Device fixity
•
Need for ‘ Bone moulding’
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79. DISTRACTION OSTEOGENESIS
TOOTH MOVEMENT THROUGH REGENERATE
The earlier views suggested that tooth
movement should not be initiated into the
regenerate.
Present views as supported by Liou and Cope
point out to the possibility of initiating
tooth movement immediately after or even
during the distraction period.
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96. DISTRACTION OSTEOGENESIS
The Orthodontist’s role
a. Decompensation of the dentition
b. Planning the distraction vector
c. Bone Moulding using intermaxillary
elastics
Functional
d. Post-distraction Orthodontics
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Fixed
97. DISTRACTION OSTEOGENESIS
Currently Unresolved issues
a. Effects of distraction on growth
b. Limits of distraction osteogenesis
c. Effects of distraction on eruption and
movement of teeth.
d. Long term stability of regenerate bone.
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98. DISTRACTION OSTEOGENESIS
Directions for the future
a. Refinements in the distraction protocol
b. Improvement in distraction devices
c. Enhancement of regenerate maturation
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