Richard Burton, DDS, MS, Professor of Oral and Maxillofacial Surgery
University of Iowa College of Dentistry

First Published: May 2001
Last Revised: May 2001
Peer Review Status: Internally Peer Reviewed

Distraction osteogenesis is a new variation of more traditional orthognatic surgical procedures for the correction of dental facial deformities. It is most commonly used for the correction of more severe deformities and syndromes that were untreatable in the past. It can be applied to both the maxilla and the mandible and can be used in children at ages previously untreatable. It has shown excellent results with both predictability and stability of results.

What is the recovery time like?

The recovery period is determined by the jaw in which the surgery is done and the type of device utilized for the distraction. Hospitalization is usually only overnight, and the period of both distraction and retention can be completed at home with the person maintaining a nearly normal lifestyle.

Can children have this procedure done, if they have a malformed jaw?

Children can have these procedures done. We are currently performing the surgery on children in the lower jaw at under 1 year of age and in the upper jaw between the ages of 7 and 10 years old.

Is this considered a "risky" procedure? Any risk of nerve damage?

As with any major surgical procedure, there are risks associated with it....but in many situations these risks are outweighed by the improvement in the quality of life and function corrected by the surgery. There is in the lower jaw risk of nerve damage, but this is lower than more conventional methods and the regenerative properties of the nerve are higher in infants and children.

Is it necessary for the jaw to be wired shut afterward?

No, in both maxillary and mandibular distraction, the patient is not wired shut. The patient has movement of the jaws but does not have normal chewing function and usually is maintained on either a liquid or soft-chew diet during the distraction period.

How long does this procedure take, and what is the recovery like?

Depending on the jaw in which the surgery takes place and whether one or both sides is involved, the surgeries run between 1.5 and 4 hours. After an overnight admission to the hospital, the patients are discharged home. Initial recovery period is approximately 5 days, during which the distraction is started and continued. Distraction periods usually run between 10 and 20 days during which time the patient can resume a normal lifestyle with somewhat reduced physical activity. Active distraction is followed by a period of 6-8 weeks of retention after which the distraction devices are removed and treatment is complete.

What is the age of the youngest patient you have treated?

For lower jaw distraction, I have treated patients as young as 10 months and will be treating a 4-month-old next month. These surgeries are all in the lower jaw. The youngest upper jaw distraction has been 8 years old.

What kind of facial deformities can be fixed through this procedure?

These procedures can be used to treat a wide range of facial deformities but it is most appropriate in syndromic patients and children with conditions such as cleft palate, severe asymmetry, severe mandibular hypoplasia with resulting airway compromise, facial clefts, Treacher-Collins syndrome, Pierre-Robin sequence and hemifacial microsomia.

Would there be any visible scars?

Upper jaw distraction utilizes a rigid external halo that produces minimal scarring and is well hidden in the hairline. Lower jaw distraction can be both intraoral and extraoral. In most cases, scarring is present but not severe.

With this in young children, will their jaw still grow normally?

There appears to be growth potential in these children though in most cases they will still not grow adequately. They may require further surgery to more fully correct their deformity and establish a more functional occlusion.

Would there be a lot of swelling afterward?

Patients exhibit minimal swelling after the procedure, the majority of which resolves within 7 to 10 days, though there is some residual swelling until after completion of the distraction phase of treatment.

What kind of follow up with the doctor is needed after this procedure?

After completion of surgery and discharge home, the device will be activated between 2 and 5 days after surgery. The patient will be closely monitored during the active phase of distraction with follow-up every 3 to 5 days. After the completion of the distraction, the patient is seen every 1 or 2 weeks during the retention phase of treatment...and then monthly for 3 to 6 months.

What kind of questions should I ask my doctor before this procedure?

The kind of questions that should be asked should include a decision regarding treatment goals for distraction and the appropriateness and ability of distraction to reach that goal, what type of device will be used, how long will the device need to be worn for both distraction and retention, are other retention devices necessary after removal of the device and how long must they be worn, what type of similar patients have been done and what have their treatment outcomes been, does the device have FDA approval and how long has it been available on the market, what is the doctor's experience in treating these types of patients, and what possible alternatives are there to distraction.

How do I know if I am a candidate?

The determination for the appropriateness of distraction as a treatment modality hinges primarily upon the severity and type of deformity and the ability of other means of treatment in being able to adequately correct it. Distraction is not a treatment of last resort but is most appropriate for the more severe types of deformities or patients who require treatment at an early age, which is inappropriate for more conventional therapy.

Many times, distractions can be used as an interventional treatment in childhood to allow more normal growth and development and prevent many other developmental delays and complications. We have had a great deal of success in the treatment of severely hypoplastic mandibular development in children. The majority of these children have been tracheostomy-dependent since birth. Many times, they remained tracheostomy-dependent until their teen years, when more conventional treatment was possible. Being able to eliminate their tracheostomy prior to the beginning of development of speech allows a more normal childhood and development with a better quality of life and health and reduced total medical care costs for the patient and family.

The use of maxillary distraction, particularly in the cleft palate population, has allowed us to achieve levels of correction that are unattainable by other methods. Through distraction, midface deficiency can be corrected to a normal position. In the past, we often camouflaged our results by treating both the upper and lower jaws, because we were unable to perform the correction adequately in the upper jaw.

Is this special training needed to perform this procedure?

Also, we can correct maxillary position at a younger age, normalizing occlusion and allowing for more normal midface growth after the completion of distraction. The basis for both maxillary and mandibular distraction are surgical techniques commonly associated with orthognathic surgery, which is used to correct both dental and facial deformities in teenagers and adults. The training necessary to perform these procedures pertains mainly to the surgical application of the devices, appropriate selection of the devices, modification of the osteotomies to produce the desired results, and control and modification of the vectors of distraction during the distraction period.

How many of these procedures have you performed?

During the past year, I performed approximately 20 of these procedures, equally split between the upper and lower jaws. They usually are appropriate only to one jaw in any given patient....or treatment phase.

Can this be done for over/under bites?

It may be utilized for the correction of midface or upper jaw deficiency which has resulted in an overbite and in some cases of underbite, particularly those involving facial asymmetries. The determination for the appropriateness of distraction vs. more conventional orthognathic procedures used to correct over/underbites can best be determined in consultation with the surgeon after evaluation of and determination of the severity of correction needed.

Distraction osteogenesis in the mandible and maxilla is an exciting new treatment modality that is an extension of the techniques developed by Ilizarov 50 years ago for the treatment of long bone deformities. It has become an accepted treatment in the orthopedic community for treatment in appropriate cases. During the 1990s, we have seen its development and now utilization in the correction of both cosmetic and functional dentofacial deformities. It is a rapidly developing and evolving area in which both new devices and new techniques are constantly being developed. As it continues to evolve, it offers hope for treatment of disabled children and those with deformities so severe that in the past they were uncorrectable.

As the technology develops, we are finding better, stronger, more adjustable devices that are allowing more conservative surgeries and lower rates of complications and morbidities. Distraction osteogenesis is not intended or meant as a replacement for more conventional and sometimes conservative techniques for the correction of dentofacial deformities. It is appropriate for use in younger populations and those at the more severe end of the scale of deformity. As with all new techniques, all the answers are not known...but as the pool of patients who have been treated grows, and the experience of the providers expands and those providing the techniques expands, ongoing dialogue will allow better understanding of the techniques, their goals and their limitations.