Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

"Distraction Osteogenesis in Orthodontics:

A Comprehensive Review
1
Dr. Viraj Shyam Ingale; 2Dr. Chetan Patil; 3Dr. Pradeep Kawale; 4Dr. Pradeep Kumar; 5Dr. Snehal Bhalerao; 6Dr. Ben Joshua;
7
Dr. Aameer Parkar; 8Dr. Sachin Philip

Abstract:- Distraction osteogenesis (DO) has emerged as previous surgery. Cases of syndromic (Pierre-Robin,
a revolutionary technique in the field of orthopaedic Godenhar, Treacher Collins, Facial Clefts, Alveolar Clefts,
surgery, offering solutions for limb lengthening, bone Cranial Microsomia) or calvarial, fronto-orbital complex
deformity correction, and craniofacial reconstruction. hypoplasias, and non-syndromic bimaxillary shortening,
This article provides a comprehensive overview of the such as a retrognathic mandible in Obstructive Sleep Apnea
principles, techniques, and advancements in distraction (OSA) where orthognathic surgery is not the first choice, are
osteogenesis, highlighting its applications, challenges, indicated for DO. It can also be used to repair bite or dental
and future directions. From historical perspectives to abnormalities, such as an overbite or underbite, tooth
contemporary innovations, this review aims to elucidate movement (e.g., canine), impacted teeth, or a group of teeth
the evolution of DO and its impact on patient (e.g., anterior teeth retraction and palate expansion). DO
outcomes.Some of the downsides of DO include incorrect treatment includes the correction of alveolar atrophies, cross
vector alignment, which results in unfavourable loading biting, and occlusal plane canting. DO has been
of joints and tissues, scarring, pain, dental hygiene demonstrated to be useful in reducing orthodontic treatment
maintenance, and daily visits for activation. time [10]. DO/DH operations have an advantage over normal
Orthodontists, with their expertise in biomechanics and orthodontic and orthognathic procedures since there is no
long-term patient care, are ideally positioned to relapse caused by soft tissue histogenesis and development
[11, 12].
administer and integrate this innovative therapeutic DO/DH treatments in neonates for mandibular
treatment. advancement for airway expansion due to development
difficulties can prevent tracheostomy [13, 14]. DO can shorten
Keywords:- Distraction Osteogenesis, Orthodontics, Bone treatment duration and minimize difficulties in future
Deformity, Surgical Techniques, Therapeutic Treatment, orthodontic and orthognathic surgeries [15, 16]. Some of the
Complications. downsides of DO include incorrect vector alignment, which
results in unfavourable loading of joints and tissues,
I. INTRODUCTION scarring, pain, dental hygiene maintenance, and daily visits
for activation. Such disadvantages are mitigated by
Intraoral Distraction Osteogenesis (DO Callus developments in three-dimensional control device designs,
Distraction Histogenesis (DH) is an orthopaedic/surgical resulting in greater accuracy and less deleterious influence
process that lengthens or reshapes bones and associated soft on neighbouring tissue [17, 18].
tissues of the stomatognathic system by controlled traction
of separated bone segments, resulting in the formation of
new bone and adjacent soft tissue. These processes are based
on the fundamental biological concepts of osteogenesis and
histology. It is frequently used to address irregularities or
deformities in the jaw or other facial bones that may impair
the function or look of the face [1, 2]. Distraction
Osteogenesis dates back to Hippocrates, Codivilla (1905),
and GravrilAIllizorov (limb lengthening) [3, 4]. McCarthy et
colleagues. introduced distraction osteogenesis to the human
jaw for the first time in 1992. [1, 5]Liou and Huang [6, 7] first
used DO in orthodontic treatment in 1998, utilizing a
technique known as " Dental distraction" to rapidly retract
canines. Iseri et al. and Kisnisci et al. later devised a
separate procedure known as "dentoalveolar distraction" for
quick canine distalization by osteotomies [8, 9].Intraoral DO
can be an effective treatment for a variety of conditions,
including congenital and acquired abnormalities of the jaw,
midface, zygomatic bones, and calvarium, condylar
reconstruction in temporomandibular joint ankylosis, facial
injuries including non-healing fractures, cystic and
oncologist jaw deformities, and issues resulting from

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Fig. 1: Brief Outline of Distraction Osteogenesis

II. DEVICE can be mandibular intraoral distractors, modular internal

distractors (MID) and tooth borne distractors . Devices can
A distractor is a device made up of two pieces joined be classed as tooth-borne, bone-borne, or hybrid [19]. The
by a screw and fastened to the bones/teeth to be distracted. distraction device's material can also be used to classify it,
Distraction of segments occurs over a period of several with bioresorbable devices employed in infants with
weeks with screw activation. Distractor devices used in the congenital abnormalities and non-resorbable metallic
maxillofacial region can be classified according to their devices. Distraction techniques can also be classified into
location, such as mandibular, midface or maxillary, alveolar, two types: callotasis and distraction of the bone
or transport (neo-mandible/neocondyle reconstruction). development plate, which results in epiphysiolysis and
Devices can also be classified according to their application, chondrodiatasis. Distraction strategies can be classified into
such as (RED) Rigid External Distractors, which are three types: monofocal, bifocal, and trifocal. They are
anchored to the bone using percutaneous pins, fixation classified based on the amount of osteodistraction gaps and
clamps, and distraction rods, and Internal Distractors, which calluses caused by surgical fracture, with monofocals
can be implanted under or above the oral mucosa. External utilized for modest corrections and trifocals used for large
distractors can further be divided into unidirectional, surgical realignments [20, 21].
bidirectional and multiplanner, whereas internal distractors

Fig. 2: Types of Distraction Osteogenesis

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
III. BASIC PRINCIPLES C. Distraction
During this time, applying progressive tension to the
The appliance's position on the mandible/maxilla is soft callus interferes with the fracture's natural healing
determined by a number of factors, including the biological process. The tension caused by this traction force creates a
and mechanical forces that shape the regenerate (new bone dynamic microenvironment that encourages the formation of
formed during the active period of distraction osteogenesis) new tissue in a direction perpendicular to the traction vector.
and the desired change in shape and function [1, 22].Both During distraction, four zones emerge: a fibrous, less
biologic and mechanical forces must meet the orthodontic vascular centre with collagen fibres parallel to the
treatment goals of structural integrity, functional distraction vector, a transition zone of early bone
optimization, and aesthetics. Force transduction via nearby production, a bone remodelling zone, and mature bone at the
structures modulates tissue regeneration between bone ends. The distraction process normally progresses by 0.5 to
fragments by altering the stress generated within the callus 1 mm per day [1, 28].
[22, 23]. Stable fixation of the osteomised bone segments is
important for successful distraction, and the distraction axis REMODELING AND CONSOLIDATION
must be parallel to the bone's anatomic axis rather than the
biomechanical axis of loading to avoid undesirable joint Bone maturation initiates once the newly formed bony
loading. Clinical studies have confirmed that the device's tissue begins to resemble preexisting bone and undergoes
orientation to the mandible has a direct influence on skeletal soft tissue adaptation, continuing for a year or longer.
morphology, and the best approach to describe the device's Following cessation of distraction, the softened callus
position is in relation to the mandibular body's long axis. solidifies, predominantly through intramembranous
There are three different forms of device placement: vertical, ossification, completely filling the gap with woven bone.
horizontal, and oblique. During planning distraction, the Paediatric patients are advised to undergo a 3-5 week phase,
significant impact of biological and mechanical force while adults should consider a 6-12 week phase for
systems must be considered in order to predict their craniofacial bone distraction [29].
consequences. The velocity and rhythm of the separation
pressures influence the success of new bone formation Distraction osteogenesis encompasses a four-stage
throughout the distraction process [24, 25]. The stages of process involving a fibrous central zone, transition zone,
distraction osteogenesis are presented in the following order: remodelling zone, and mature zone. During the fibrous
central stage, mesenchymal proliferation occurs with
A. Osteotomy longitudinally oriented collagen bundles. The transition
To start and maintain the distraction osteogenesis, each stage witnesses the formation of osteoids along these
bone segment that has undergone an osteotomy must have a bundles. Remodelling occurs in the subsequent phase,
enough number of live osteocytes. Because the periosteum involving osteoclast formation and restructuring of the
in the well-vascularized craniofacial region affords nascent bone. The final stage, the mature zone, marks the
significant osteoblastic activity, complete osteotomy is not conversion of mechanical forces into cellular signals
preferable over corticotomy[26]. through mechanical transduction [30].

B. Latency Distinctive aspects of the healing process in distraction

Soft calluses are formed during the latency phase of osteogenesis compared to fracture repair include regulated
distraction osteogenesis, which follows a histology pattern microtrauma and an intramembranous ossification
similar to bone mending. The recommended first delay time mechanism, diverging from the endochondral ossification
ranges from 5 to 10 days [27]. seen in fracture healing [1, 26].

Fig. 3: Local and Systemic Responses in DO/DH

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ISSN No:-2456-2165
IV. MOLECULAR MECHANISM bone homeostasis and regeneration, highlighting the
interconnectedness of mechanical stimuli, gene activation,
The Distraction Osteogenesis/Distraction Histogenesis and chemical response at molecular and cellular levels. The
(DO/DH) technique harnesses the regenerative potential of DH process relies on the production of Endothelial
musculoskeletal tissues, triggering various regulatory Progenitor Cells (EPCs) and their homing to the site of new
processes. Research utilizing next-generation sequencing, bone production. Activation of VEGF receptors 1 and 2 is
proteomics, and metabolomics is uncovering the molecular crucial for neovascularization and bone production during
pathways involved in DO/DH. Tension stress during DO/DH DO. Hypoxia-induced factor 1 and mechanical manipulation
impacts signal transduction molecules, BMPs, inflammatory during consolidation influence the paracrine loop of VEGF
and vascular proteins, and epigenetic factors, with ongoing and BMP-2, maintaining the coupling of angiogenesis and
exploration to enhance clinical applications. During DH, osteogenesis. Transportation of bone marrow and adipose-
inflammatory and immunomodulatory reactions are pivotal derived MSCs has been shown to expedite bone
for bone homeostasis, with high levels of tensile strain consolidation in DO and DH models, with growth hormones
inducing the expression of pro-inflammatory genes like and EP2-specific agonists investigated for improving bone
Prostaglandins and COX2. Bone remodelling, essential for regeneration. Post-transcriptional regulation of DO/DH-
medullary cavity recanalization during late consolidation in related genes relies heavily on small non-coding RNAs
DO, can be regulated by PEMF, ultrasound, and shock wave (mRNAs), and various scaffolding materials are under
therapies. Mechanotransductionsignalling mechanisms such investigation to promote bone development and
as YAP, TAZ, and ERK-1/2 stimulate genes responsible for consolidation.

Fig. 4: Clinical Applications

V. CLINICAL IMPLICATIONS FOR drawbacks, enabling occlusal adjustments and micro-

MAXILLOFACIAL APPLICATIONS OF management during distraction. Paediatric patients typically
DISTRACTION OSTEOGENESIS avoid external devices unless airway concerns arise.

Clinical implications for maxillofacial applications of In patients with active growth, distraction procedures
distraction osteogenesis revolve around device design, are deferred until growth maturity due to bone elasticity.
configuration, sturdiness, and attachment stability, all of Osseodistraction with corticotomy of the external cortex is
which significantly impact procedural success. Factors such advised in younger individuals. Adults, with a more resistant
as distraction device orientation, operational vector internal cortex, exhibit reduced failure risks. A latency
alignment with anatomical axes, bone geometric period of 4–7 days post-osteotomy precedes distraction, with
morphometrics, cross-sectional area, density, transport-gap premature bone union more likely if delayed beyond 10 to
length, and soft tissue tension influence the quality of tissue 14 days. The gold standards for craniofacial distraction
generated. osteogenesis include a distraction rate of 1mm/day and a
delay of 5 to 7 days.
Choice between external and internal devices is a key
planning factor. External devices offer three-dimensional Recent maxillofacial procedures involving distraction
transportation capability and optimal vector generation but osteogenesis, often conducted collaboratively with
may result in facial scarring and increased distance between orthodontists, adhere to these principles to achieve optimal
force points, with limited ability to alter force direction post- outcomes.
insertion. Internal devices, though smaller, overcome these

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VI. DENTO-ALVEOLAR DISTRACTION and severe dysphmorphism, especially in syndromic
craniofacial synostosis with exorbitism and cranial
Chin and Toth [45] introduced vertical mandibular microsomia (can be treated with combined maxilla-
alveolar distraction osteogenesis to clinical practice in 1996. mandibular distraction). [52]
Block et al. validated distraction osteogenesis for alveolar
ridge augmentation in the mandibular canine. IX. CRANIAL DISTRACTION
Osteodistraction of the alveolar process is more effective for
three-dimensional reconstruction than grafting or tissue In one of the early clinical trials, Polley et al. used a
regeneration. Alveolar ridge distraction is advised to fixed cranial halo to distract the midface. The benefits and
improve bone volume for implant insertion and orthodontic drawbacks of Rigid External Distraction (RED) are the same
tooth movement. as those outlined in other distraction treatments. Figueroa et
al. exhibited complete clinical regeneration of hard and soft
VII. MANDIBULAR DISTRACTION tissues in the midface with distraction. Maxillary Le Fort I
distraction is recommended for retrusion/protrusion in
Snyder et al. verified the clinical application of patients with Cleft Lip and Palate who have associated
Ilizarov’s bone lengthening principles for facial and jaw dental and soft tissue issues. Other indications for Midfacial
areas, employing an external distractor for canine Distraction with Maxillary Le Fort III distraction for
distraction. McCarthy et al. and Guerrero utilized external midface retrusion include respiratory issues, malocclusion,
distractors for treating congenital facial defects and mid- and severe dysphmorphism, especially in syndromic
symphyseal widening with a hyrax-type screw, respectively. craniofacial synostosis with exorbitism and cranial
These techniques were applied in patients with facial microsomia (can be treated with combined maxilla-
dysmorphism, respiratory issues, and conditions such as mandibular distraction). [52]
Pierre Robin syndrome, Treacher Collins syndrome,
micrognathia, and craniofacial microsomia. They were also X. ORTHODONTIC TREATMENT PROTOCOL
used for managing temporomandibular joint ankylosis and
post-ablative mandibular problems, as well as infant or  Pre-distraction orthodontic treatment encompasses tasks
paediatric patients with sleep apnea or swallowing such as levelling, alignment, coordination of maxillary
difficulties. and mandibular arches, and decompensation. This
involves positioning teeth over the basal arch and
Placement of intraoral or external devices involves inducing root divergence at the osteotomy site to
trans-cutaneous (submandibular) or intraoral incisions. facilitate subsequent procedures.
Comparison of distraction-based osteotomies to  Orthodontic interventions during the distraction and
conventional ones shows advantages such as earlier surgery, consolidation phases involve the use of intramaxillary
shorter procedures, fewer postoperative complications and/or intermaxillary elastics, mini implants, and
(including transfusions), and reduced need for additional headgear to initiate movement towards the post-
surgeries (such as grafts). Additionally, the lengthening or distraction position. These measures also aid in
expansion of muscles and soft tissue above (distraction controlling clockwise or counterclockwise rotation of
histogenesis) over time leads to decreased relapse rates. distracted segments based on evolving clinical needs.
Orthodontic adjustments during this stage provide three-
A. Periodontal ligament distraction dimensional control in the horizontal, vertical, and
In 1998, Liou and Huang identified osteogenesis in the transverse dimensions, establishing an optimal
periodontal ligament during rapid orthodontic tooth biomechanical system for correcting distracted segments.
movement, which is similar to osteogenesis in the mid-  Post-distraction orthodontic care focuses on finalizing
palatal suture during rapid palatal expansion. Distractor residual dentoalveolar movements, refining occlusion,
activation at 1mm/day, along with interseptal bone fracture aligning roots, and artistically positioning teeth to
of the extraction socket, has been shown to shorten achieve functional occlusion and desirable facial
orthodontic treatment time by 3-4 months [50, 51]. aesthetics.
 Retention of the achieved dentoalveolar and bone shape
VIII. MAXILLOFACIAL AND MID FACE and position is achieved through the use of fixed or
APPLICATIONS removable retainers.

In one of the early clinical trials, Polley et al. used a

fixed cranial halo to distract the midface. The benefits and
drawbacks of Rigid External Distraction (RED) are the same
as those outlined in other distraction treatments. Figueroa et
al. exhibited complete clinical regeneration of hard and soft
tissues in the midface with distraction. Maxillary Le Fort I
distraction is recommended for retrusion/protrusion in
patients with Cleft Lip and Palate who have associated
dental and soft tissue issues. Other indications for Midfacial
Distraction with Maxillary Le Fort III distraction for Fig. 5: Extrusion of Impacted Teeth
midface retrusion include respiratory issues, malocclusion,

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Experimental studies have shown that after four days the drawbacks of prolonged external distractor wear.
of consolidation, the load-bearing group exhibited a higher Disorders involving vascularity and circulation, such as
percentage of regenerated bone and elevated levels of diabetic ulcers, also show potential for correction with
osteocalcin, type I collagen, and morphogenetic proteins 2 DO/DH, as demonstrated in the treatment of thromboangitis
and 4 (BMP-2 and BMP-4). Various extracellular matrix obliterans.
(ECM) proteins, cytokines, and growth factors play essential
roles in bone formation processes at the distraction gap. Research in DO/DH is expected to expand our
According to Okazaki et al., recombinant human fibroblast understanding of tissue regeneration, including neural
growth factor (FGF) was utilized towards the end of the regeneration in vascular and neurological disorders. While
distraction period. The effectiveness of distraction DH traditionally employs minimally invasive approaches
osteogenesis (DO) has been underscored by ECM proteins like ultrasound and electromagnetic stimulation, current
like osteocalcin, whose mRNA and protein expressions vary methods, such as local transport of undifferentiated cells and
throughout the distraction phases. These regulatory factors mechanotransduction-induced molecules, as well as
experience changes in mRNA and protein expressions hormone injections, are poised to enhance bone growth and
during distraction stages, emphasizing the importance of favor distraction procedures for improved clinical outcomes.
timing the administration of specific proteins for optimal
results. Ongoing research in these areas aims to further our
understanding of basic biological processes, laying the
Protecting the main sources of osteoblast precursors, groundwork for enhanced therapeutic applications of the DH
namely the periosteum and endosteum, from heat or approach.
mechanical damage during surgery is crucial for successful
osteogenesis. Adequate blood supply to the distraction site is  Acknowledgement: Nil.
essential for osteogenesis, necessitating careful attention to  Conflict of Interest: Nil.
ensure proper vascularization of the soft tissues near the  Financial Support: Nil.
potential distraction site. Arterial insufficiency during
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