The Indications and Treatment

Planning of the Distraction

Devices
2

Indication

Indication
Wide variation in these days

Hypoplastic Mandible
Missing bone as a consequency of
pathology
Craniofacial microsomia
Micrognathia
Midface deficiency

Indication
Calvarial expansion in craniosynostosis
Severe resorbed alveolar bone
Dental implant placement
Alveolar cleft
Periodontal ligament distraction
Pediatric sleep apnea

Hypoplastic mandible,
Hemifacial Microsomia,
Congenital
anormaly
Micrognathia.
Pierr Robin syndrome,
Bliateral microsomia,
Treacher Collin syndrome,
Nagars syndrome, etc.

Severe malocclusion especially

Class II occlusal relation.

Hypoplastic mandible, Hemifacial

Microsomia, Micrognathia.
Classification of Mandibular Hypoplasia (Pruzanski)
Grade 1 : hypoplasia affects only the gonial angle
Grade 2A : the angle and ascending ramus are affected
Grade 2B : hypoplasia is more severe and affects
the angle and ascending ramus
Grade 3 : complete absence of the ramus and condyle

Mn lengthening and widening

Missing bones as a sequence

of pathology
Bone Transport
The gradual movement of a free
segment of bone (transport
segment or transport disk)
across the osseous defect

Missing bones as a sequence

of pathology
Variations
Neocondyle construction
Cleft palate reconstruction
Velopharyngeal insuficiency.

Midface deficiency
midface deficiency,
craniofacial dysplasias,
facial clefts.
Rigid external distraction (RED) system
Three-Dimensional Midface distraction

device
Internal distraction device

Calvarial expansion in
craniosynostosis
Conventional bone graft method reveals the
insufficiency of quantity of bone and dead
space occuring leading to postoperative
infection, bone resorption, and relapse.
patients with complex or reccurent
abnormalitie resulting in limited craniofacial
growth

Severe resorbed alveolar bone

and dental implant placement
Atrophic alveolar process
Vertical and horizontal distracton is
used.

Alveolar cleft
Patients with insufficien secondary
bone alveolar graft
Vertical osteotomy is applied on pregrafted bone and miniplate must be
fastened under the nasal mucosa.

Periodontal ligament
distraction.
The movement of canine after extraction
of premolar tooth.
Rapid canine movements is for the
adult patients required short treatment
times and maximum anchorage
construction

Pediatric sleep apnea.

For the infants and late childhoods with
OSAS caused by mandibular hypoplasia,
distraction devices can eliminate the
necessity for tracheostomy and correct
feeding and esthetic problems.

Treatment planning
of distraction
device.

Patient selection
Patient age.
Sex.
Metabolic disturbance of bone.
Problem of breathing and food intaking,
Susceptibility to infection.
Psychosocial stability.
Skin texture (kelloid),

Considering Factor
Surgical correction,
Potential for the future skeletal
growth and developement
Need for overcorrection
Possible future operation.

Specific distraction related

decisions
Osteotomy design and location
Selection of a distraction device
Determination of the distraction vector
Duration of the latency period
Rate and rhythm of distraction
Duration of the consolidation period.

Distraction Device Selection

External or internal Deistraction
Devices ?
How long distance should practicer
expect?
How can distracted bone move?

External Deistraction Devices

Advantage :
Excellent control of bone segment movement
available in longer lengths
Easier to place, maintain, replace and remove.
Disadvantage
Scarring
Poor acceptance by patients

Internal Distraction Devices

Advantage
Not produce facial scarring
Negative psychologic effect of external devices.
Disadvantage
Difficult to place
High risk of injury to anatomic structure.
Second surgical procedure is necessary to

remove the devices

Lengthening Capabilities
The actual bone distraction, which is usually
less than anticipated and difficult to predict
prior to distraction.
Soft tissue interference. Vector of
ostetomy line and device.

Direction of Distraction
Unidirectional or multidirectional?

Decision of the vector.

Distraction Device Orientation
Influence of Masticatory Muscles
Occlusal Interferences
Distraction Device Acivation
Orthodontic/Orthopedic forces

Distraction Device Orientation

Vertical distraction : parallel to occlusal plane
Horizontal distraction : true AP advance
Oblique distraction : Vertical and horizontal
movement simultaneously.

Influence of Masticatory
Muscles
Induced recurrent episodic forces
Soft tissue traction due to physiologic muscle activity
exerted contribute to distal segment directional
instability.
Such movement can be altered by making
adjustment in sequence and amount of activation of
the multidirectionla device

Occlusal Interferences
Posterior occlusal interferences
Stepping posterior teeth off of the occlusal plane
Utilization or biteplane or biteblock appliances,
orthodontic adjustment, occlusal equibrium..
Anterior occlusal interference
Advancing, proclining, intruding the maxillary
anterior teeth.
Using biteplane of biteblock

Distraction Device Acivation

In saggital plane
~Rotation of the entire mandible around the axis
located at the condyle
open or close the bite anteriorlly
~ Reduces the anteroposterior length of the mandible
and must be accompanied by additional linear
distraction
In transverse plane
~ Affected by the resistance of TMJ posteriorly,
symphysis anteriorly
~ Proximal (condylar) segment is smaller,
so less resistant to reactive forces, more
dramatically affected.

Orthodontic/Orthopedic forces
During the active distraction phase and
consolidation phase
~ Intermaxillary elastics, headgear,
functional appliances

Future growth and

Overcorrection
skeletal age and age and future growth potential must be
considered.
~ If future growth is expected to be deficient,
overcorrection may be performed
~ Must consider psychosocial impact, race, sex,
facial skeleton maturity
~ The existing growth pattern may be
maintained and the discrepancy may resurface
again with time.

Presurgical Orthodontic
Preparation
Evaluation of the dentition and its relation to the
projected skeletal changes.
Elemination of dental malrelationships
Tooth position and maxillary width should enhance
distraction, not inhibit it.
Fabrication and utilization of distraction stabilization
appliance

To direct the distal mandibular segment

Orthodontic
Management
toward its planned postdistraction
during
and
position,distraction
thereby improving
the final
treatment
result
consolidation
~ Interarch elastic traction is useful for the

control of anterior distal segment movement in

excess of what is desired especially excessively
oblique device placement.

Postconsolidation orthodontic
therapy
To support new bone at the distraction gap.
Bilateral Distraction
~ In anticipation of a future mandibular
growth deficiency.
~ Guidance of eruption and alignment of the dentition
~ Growing children planned future orthognathic surgery
or distraction

Postconsolidation orthodontic
therapy
Unilateral distraction:
Occlusal plane management
Correction of dental midline
Correction of the maxillomandibular transverse
disharmony
If closing of the posterio openbite is failed, correction of
the occlusal canting cannot be possible. In this case,
surgical correction of the compensated occlusal plane
(bimaxillary osteotomy) can be considered.