distraction osteogenesis


Distraction Osteogenesis, or simply “Distraction” is a surgical technique that allows us to change the position or length of bones.  In patients with cleft palate, mid-face growth restriction can cause the upper jaw to seem sunken in and flat relative to the lower.  The upper teeth can fall behind the lower teeth creating an underbite.  Distraction may be a great way to correct this.

There are generally two ways to correct this jaw mismatch.  First, we can cut the bones above the upper jaw and move it forward, securing it with metal plates and screws.  This is called a Lefort I Advancement.  (Lefort was the name of the doctor that first described similar fractures of the facial bones).  Lefort I Advancement has a few major drawbacks.  The first is that in order to place the necessary screws, we need to wait until the adult teeth have moved down out of the way.  When baby teeth are still present, adult tooth buds are high in the bone making this operation impossible.  In order to do this surgery, the baby teeth must be gone and the adult teeth much be in.  This usually happens at about 16 years of age.  That may be a long time for a child to wait to have correction of their facial structure.  The second drawback is that advancement has a high rate of “relapse”.  This means that the jaw can settle back where it came from despite the metal plates and screws.  Even with these drawbacks, Lefort I Advancement can be a great technique for the right patient because the operation allows for correction of the problem in one procedure.

The second method is Lefort I Distraction.  In this technique, we cut the bones in exactly the same way we do with advancement, but instead of moving the jaw and securing it with plates and screws, we move it forward slowly over several weeks.  This allows the body to create new bone as the jaw moves forward.  This helps to significantly limit the risk of relapse.  Distraction also can be done at any age because it does not require plates and screws.  So kids can be treated at a much younger age.  The downside is that patients need to wear a “halo” device that moves the upper jaw, and then holds it as it heals, for up to 3 months.  Kids generally tolerate this procedure well and many still go to school with the halo in place.  Other families opt to homeschool or have the surgery during the summer when kids are out of school.

The halo device attaches directly to the skull using screws that anchor it.  This seems like a painful procedure, but children do very well and do not complain of pain while the halo is in place.  The halo can even be very easily removed in the office without discomfort at the end of treatment.  The halo head-frame is attached to two activation arms that are in turn attached to an appliance that is connected to the teeth.  By turning a threaded screw on the activation arm, the upper jaw is slowly moved forward by one millimeter per day.  The activation of the device is painless and is done by parents or caregivers.  Frequent visits to the doctor are made for minor adjustments and to make sure the distraction is going as planned.  The distraction phase lasts 2-3 weeks including a few days in the hospital after surgery.  Once the jaw is in the correct position, the distraction is stopped and the device is left in place to hold the jaw in position as the bone starts to heal.  This holding phase, or consolidation phase, lasts 6-8 weeks.

Click here for more information of the Lefort I Osteotomy.

Other options may also be available.  These can be discussed with Dr. Warnock.

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