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EDITORIAL
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 113

To distract or not to distract


Director and Consultant Maxillofacial Surgeon, Balaji Dental and Craniofacial Hospital, 30, KB Dasan Road, Teynampet, Chennai - 600 018, India

Date of Web Publication3-Oct-2013

Correspondence Address:
S M Balaji
Director and Consultant Maxillofacial Surgeon, Balaji Dental and Craniofacial Hospital, 30, KB Dasan Road, Teynampet, Chennai - 600 018
India
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DOI: 10.4103/2231-0746.119210

PMID: 24205469

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How to cite this article:
Balaji S M. To distract or not to distract. Ann Maxillofac Surg 2013;3:113

How to cite this URL:
Balaji S M. To distract or not to distract. Ann Maxillofac Surg [serial online] 2013 [cited 2019 Oct 17];3:113. Available from: http://www.amsjournal.com/text.asp?2013/3/2/113/119210

Distraction Osteogenesis (DO) for craniofacial applications is not new and has been there for decades. DO offers an excellent choice for creating new bone in all dimension along with adjacent soft tissue including nerves. This is accomplished by gradual and controlled displacement of bone fragments created by surgical cut. The gradual traction force applied remodels the callus formed. Though initially suggested for long bones, its use in craniofacial defect revolutionized craniofacial surgery. [1],[2]

The cue to success with DO lies with understanding the basis of DO, vectors of forces, growth characteristics of jaw, and facial bones as well as the molecular mechanism of bone formation and remodeling. Primarily, the placement of surgical cut, angulation, vector principles, direction of the distractor, and the rate of distraction dictates the outcome. The choice of external or internal distractors also needs to be considered. External distractors are often bulkier and cause discomfort during distraction and consolidation phases, besides the unesthetic scar. Case selection has been largely ignored till date. DO is not a single stop solution to all defects. Given the complex structure and anatomy of the facial bones, sufficient care has to be exercised to opt for DO for structural loss. [3]

When a case can be managed effectively by a conventional technique such as osteotomy, use of DO is certainly not recommended. In my personal opinion, in cases which require maxillary expansion, DO is most useful and far more superior than conventional techniques. When the disorder arises from a pathological process that has not ceased, DO failure is eminent. When DO is performed after cessation of growth and stabilization of defect, it yields good and expected result. This is most favorable for microsomia cases. [4]

In situation of single directional defect such as early temporomandibular joint (TMJ) ankylosis that leads to stunted growth in terms of length, simple DO will yield better result. When there is bidirectional defect, as in hemifacial microsomia, where the deficiency of length and height of the jaw bone are observed, complex bi-directional distractors need to be employed. In instances of atrophy, multivector or curvilinear vectors may be needed to produce esthetically approvable results. [1] Still the surgeon's knowledge and experience in handling the vectors becomes crucial in creating the best outcome. Uncontrolled or unsupervised DO would lead to overgrowth of the involved side, causing a midline shift. Simultaneous occlusal cant correction through osteotomies may be beneficial in certain cases. Management of open bites arising out of unfavorable vectors requires considerable expertise. In cases which had undergone prior surgeries, bone quality may not be uniform that may yield differential rate of growth causing variation in vectors. In situations such as presence of insufficient bone, use of rhBMP2 at the docking site will yield good results. Certain systemic illness and certain drug therapies could impede DO. Certain cases and situation will not yield better result with DO. Hence this versatile technique needs to be used with extreme caution.

This issue comes with new innovation in Maxillofacial Surgery. Considering the valuable information and innovations, exempt has been made with respect to word count. Wolff and Sandor's team have shown the efficacy of adipose stem cells to treat critical sized defects of jaws, whereas the teams from Germany have shown their initial results with a new reconstruction material. Hope such new innovations and methodology expand the frontiers of Maxillofacial surgery.

 
  References Top

1.Balaji SM. Trifocal, bilateral reconstruction of mandible using Guerrero's two-stage transport disc distraction with a plate guided reconstruction plate: A modified technique. J Maxillofac Oral Surg 2008;7:226-9.  Back to cited text no. 1
    
2.Salokorpi N, Sándor GK, Sinikumpu JJ, Ylikontiola L, Serlo W. A new technique to facilitate optimal directions for cranial distractor implantation. Childs Nerv Syst 2013;8:1359.  Back to cited text no. 2
    
3.Ylikontiola LP, Sándor GK, Salokorpi N, Serlo WS. Experience with craniosynostosis treatment using posterior cranial vault distraction osteogenesis. Ann Maxillofac Surg 2012;2:4-7.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Balaji SM. Change of lip and occlusal cant after simultaneous maxillary and mandibular distraction osteogenesis in hemifacial microsomia. J Maxillofac Oral Surg 2010;9:344-9.  Back to cited text no. 4
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