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Tooth-borne distraction to widen the mandible technical note
Copyright © Munksgaard 2000
Int. J. Oral Maxillofac. Surg. 2000; 29:27-28 Printed #z Denmark. All rights reserved
lntemadonalJoumalof
Oral& MaxillofacialSurgery ISSN 0901-5027
Tooth-borne distraction to widen the mandible
B. Niederhagen 1, B. Braumann 2, S. Bergd 1, J.-J. von Lindern ~, T. Appel ~ 1Departmentof Oral and Maxillofacial Surgery; 2Dental School, Department of Orthodontics, University of Bonn, Germany
Technical note B. Niederhagen, B. Braumann, S. Bergd, J.-J. yon Lindern, T. Appel: Tooth-borne distraction to widen the mandible. Int. J. Oral Maxillofac. Surg. 2000; 29." 27-28. © M u n k s g a a r d , 2000 Abstract. Based on r e p o r t e d animal studies, the case r e p o r t presented d e m o n s t r a t e s the use o f t o o t h - b o r n e distraction osteogenesis for m a n d i b u l a r widening o f 1 c m in order to avoid extraoral distraction devices. D e t r i m e n t a l side effects on healthy a n c h o r i n g teeth are n o t likely.
Case report At the age of 32, the patient suffered multiple trauma with extensive centrolateral midfacial fractures on the right, a sagittal fracture of the maxilla, a subcondylar fracture on the left, and several comminuted anterior mandibular fractures. Due to the accident having occurred abroad, the fractures were not treated until 2 months after the trauma. One year after surgery, the patient showed constriction of the mandible and extensive transverse enlargement of the maxilla with resultant malocclusion of the premolar and molar areas on both sides (Fig. la). Revisional surgery to narrow
the maxilla using a Le Fort I osteotomy was complicated by excessive bleeding and followed by a complete relapse to the previous situation after 3 months.
Surgical technique After discussing the treatment plan with the orthodontist, distraction osteogenesis of the mandible using a tooth-borne distraction device was carried out to widen the mandible. The method had been previously tested in an experimental model 1=3. An apparatus with a lingually situated dilating screw, usually applied for rapid palatal expansion (Dentau-
Key words: tooth-borne device; distraction osteogenesis; mandibular widening. Accepted for publication 6 August 1999
rum, Ispringen, Germany), was individually manufactured and fixed to the mandibular first premolars and first molars using glass ionomer cement (Fig. 2a). Osteotomy of the left mandible in the region of the lateral incisor was carried out intraorally under general anaesthesia, using an oscillating saw and a chisel. From the 7th postoperative day, the mandible was distracted 1 mm per day to a maximum extension of 9 mm without damage to the surrounding soft tissue (Figs. lb, 2b, 3a). After completion of the distraction, the apparatus was blocked and then removed after a consolidation period of 12 weeks. In clinical
Fig. la. Preoperative malocclusion of patient Clue to constriction of mandible and widening of maxilla. Fig. lb. Postoperative occlusion 16 days after completion of 9 mm distraction.
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Niederhagen et al.
Fig. 2a. Preoperative occlusal view of mandible with tooth-borne distraction device in situ. Fig. 2b. Postoperative occlusal view of mandible 16 days after end of 9 mm distraction.
Fig. 3a. Radiograph of mandible 16 days after end of distraction, showing distraction gap of 9 mm. Fig. 3b. Radiograph of mandible 4 months after end of distraction, suggesting nearly mature bone in area of distraction.
terms, the mandibular segments were still somewhat mobile at this time. No loosening of teeth was apparent. Orthodontic retaining treatment began immediately after removal of the distraction device. Six months after the end of distraction, the mandible was clinically stable and the radiograph showed the distraction gap filled with mature bone (Fig. 3b). Orthodontic treatment was necessary for final correction of the occlusion.
Discussion Based o n r e p o r t e d a n i m a l studies 1-4, t o o t h - b o r n e distraction osteogenesis seems feasible to widen or l e n g t h e n the h u m a n m a n d i b u l a r arch. WZIL et al. 5 previously r e p o r t e d o n t o o t h - b o r n e dist r a c t i o n for the correction o f transverse m a n d i b u l a r deficiency. However, the nine patients in this study were simultaneously treated with r a p i d palatal exp a n s i o n a n d the m e a n e x p a n s i o n in the a n t e r i o r m a n d i b l e was only 3.9 ram.
T h e case presented d e m o n s t r a t e s the use o f t o o t h - b o r n e distraction for m a n dibular widening of nearly 1 cm witho u t simultaneous t r e a t m e n t o f the maxilla. E x t r a o r a l distraction a n d the associated drawbacks, such as scarring, c a n be avoided in these cases. Detrim e n t a l effects o n healthy a n c h o r i n g teeth are n o t likely. T h e individual m a n u f a c t u r i n g o f the distraction device m u s t be regarded as a disadvantage.
References 1. BRAUMANNB, NIEDERHAGENB, SCHMOLKE C. Mandibular distraction osteogenesis - preliminary results of an animal study with a dentally fixed distraction device. J Orofac Orthop 1997: 58: 298305. 2. HOLLIS BJ, BLOCK MS, GARDINER D, CHANG A. An experimental study of mandibular arch widening in the dog
using distraction osteogenesis. J Oral Maxillofac Surg 1998: 56: 330-8. 3. NIEDERHAGENB, Bm~tnV~yN B, Scrn~oLr~ C. Distraction osteogenesis of the mandible by a dental expansion device. J Craniomaxillofac Surg 1996: 24: 147. 4. NIEDERItAGEN B, BRAUMANNB, SCI-IMOLV~ C. Tooth-borne distraction of the mandible. An experimental study. Int J Oral Maxillofac Surg 1999: 28: 475-9. 5. WEIL TS, VAN SICKELSJE, PAYNE CJ. Distraction osteogenesis for correction of transverse mandibular deficiency: a preliminary report. J Oral Maxillofac Surg 1997: 55: 953-60. Address: Dr. Dr. Bernd Niederhagen Klinik und Poliklinik ffir Mund-, Kieferund Gesichtschirurgie der Universitdt Bonn Sigmund Freud Str. 25 D-53105 Bonn, Germany Tel. +49 228 287 6385 Fax: +49 228 287 4334 e-mail: [email protected]
Int. J. Oral Maxillofac. Surg. 2000; 29:27-28 Printed #z Denmark. All rights reserved
lntemadonalJoumalof
Oral& MaxillofacialSurgery ISSN 0901-5027
Tooth-borne distraction to widen the mandible
B. Niederhagen 1, B. Braumann 2, S. Bergd 1, J.-J. von Lindern ~, T. Appel ~ 1Departmentof Oral and Maxillofacial Surgery; 2Dental School, Department of Orthodontics, University of Bonn, Germany
Technical note B. Niederhagen, B. Braumann, S. Bergd, J.-J. yon Lindern, T. Appel: Tooth-borne distraction to widen the mandible. Int. J. Oral Maxillofac. Surg. 2000; 29." 27-28. © M u n k s g a a r d , 2000 Abstract. Based on r e p o r t e d animal studies, the case r e p o r t presented d e m o n s t r a t e s the use o f t o o t h - b o r n e distraction osteogenesis for m a n d i b u l a r widening o f 1 c m in order to avoid extraoral distraction devices. D e t r i m e n t a l side effects on healthy a n c h o r i n g teeth are n o t likely.
Case report At the age of 32, the patient suffered multiple trauma with extensive centrolateral midfacial fractures on the right, a sagittal fracture of the maxilla, a subcondylar fracture on the left, and several comminuted anterior mandibular fractures. Due to the accident having occurred abroad, the fractures were not treated until 2 months after the trauma. One year after surgery, the patient showed constriction of the mandible and extensive transverse enlargement of the maxilla with resultant malocclusion of the premolar and molar areas on both sides (Fig. la). Revisional surgery to narrow
the maxilla using a Le Fort I osteotomy was complicated by excessive bleeding and followed by a complete relapse to the previous situation after 3 months.
Surgical technique After discussing the treatment plan with the orthodontist, distraction osteogenesis of the mandible using a tooth-borne distraction device was carried out to widen the mandible. The method had been previously tested in an experimental model 1=3. An apparatus with a lingually situated dilating screw, usually applied for rapid palatal expansion (Dentau-
Key words: tooth-borne device; distraction osteogenesis; mandibular widening. Accepted for publication 6 August 1999
rum, Ispringen, Germany), was individually manufactured and fixed to the mandibular first premolars and first molars using glass ionomer cement (Fig. 2a). Osteotomy of the left mandible in the region of the lateral incisor was carried out intraorally under general anaesthesia, using an oscillating saw and a chisel. From the 7th postoperative day, the mandible was distracted 1 mm per day to a maximum extension of 9 mm without damage to the surrounding soft tissue (Figs. lb, 2b, 3a). After completion of the distraction, the apparatus was blocked and then removed after a consolidation period of 12 weeks. In clinical
Fig. la. Preoperative malocclusion of patient Clue to constriction of mandible and widening of maxilla. Fig. lb. Postoperative occlusion 16 days after completion of 9 mm distraction.
28
Niederhagen et al.
Fig. 2a. Preoperative occlusal view of mandible with tooth-borne distraction device in situ. Fig. 2b. Postoperative occlusal view of mandible 16 days after end of 9 mm distraction.
Fig. 3a. Radiograph of mandible 16 days after end of distraction, showing distraction gap of 9 mm. Fig. 3b. Radiograph of mandible 4 months after end of distraction, suggesting nearly mature bone in area of distraction.
terms, the mandibular segments were still somewhat mobile at this time. No loosening of teeth was apparent. Orthodontic retaining treatment began immediately after removal of the distraction device. Six months after the end of distraction, the mandible was clinically stable and the radiograph showed the distraction gap filled with mature bone (Fig. 3b). Orthodontic treatment was necessary for final correction of the occlusion.
Discussion Based o n r e p o r t e d a n i m a l studies 1-4, t o o t h - b o r n e distraction osteogenesis seems feasible to widen or l e n g t h e n the h u m a n m a n d i b u l a r arch. WZIL et al. 5 previously r e p o r t e d o n t o o t h - b o r n e dist r a c t i o n for the correction o f transverse m a n d i b u l a r deficiency. However, the nine patients in this study were simultaneously treated with r a p i d palatal exp a n s i o n a n d the m e a n e x p a n s i o n in the a n t e r i o r m a n d i b l e was only 3.9 ram.
T h e case presented d e m o n s t r a t e s the use o f t o o t h - b o r n e distraction for m a n dibular widening of nearly 1 cm witho u t simultaneous t r e a t m e n t o f the maxilla. E x t r a o r a l distraction a n d the associated drawbacks, such as scarring, c a n be avoided in these cases. Detrim e n t a l effects o n healthy a n c h o r i n g teeth are n o t likely. T h e individual m a n u f a c t u r i n g o f the distraction device m u s t be regarded as a disadvantage.
References 1. BRAUMANNB, NIEDERHAGENB, SCHMOLKE C. Mandibular distraction osteogenesis - preliminary results of an animal study with a dentally fixed distraction device. J Orofac Orthop 1997: 58: 298305. 2. HOLLIS BJ, BLOCK MS, GARDINER D, CHANG A. An experimental study of mandibular arch widening in the dog
using distraction osteogenesis. J Oral Maxillofac Surg 1998: 56: 330-8. 3. NIEDERHAGENB, Bm~tnV~yN B, Scrn~oLr~ C. Distraction osteogenesis of the mandible by a dental expansion device. J Craniomaxillofac Surg 1996: 24: 147. 4. NIEDERItAGEN B, BRAUMANNB, SCI-IMOLV~ C. Tooth-borne distraction of the mandible. An experimental study. Int J Oral Maxillofac Surg 1999: 28: 475-9. 5. WEIL TS, VAN SICKELSJE, PAYNE CJ. Distraction osteogenesis for correction of transverse mandibular deficiency: a preliminary report. J Oral Maxillofac Surg 1997: 55: 953-60. Address: Dr. Dr. Bernd Niederhagen Klinik und Poliklinik ffir Mund-, Kieferund Gesichtschirurgie der Universitdt Bonn Sigmund Freud Str. 25 D-53105 Bonn, Germany Tel. +49 228 287 6385 Fax: +49 228 287 4334 e-mail: [email protected]