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British Journal of Oral and Maxillofacial Surgery (2001) 39, 169–178 BRITISH
© 2001 The British Association of Oral and Maxillofacial Surgeons
doi: 10.1054/bjom.2001.0642, available online at http://www.idealibrary.com on Journal of
Oral and
Maxillofacial
Surgery

Positional changes and stability of bone segments during simultaneous

bilateral mandibular lengthening and widening by distraction

M. Gonzalez,* W. H. Bell,† C. A. Guerrero,‡ P. H. Buschang,§ M. L. Samchukov¶

*Oral Surgeon, Santt Rosa Maxillofacial Surgery Center; Caracas; Venezuela; †Private Practice, Oral and
Maxillofacial Surgery, Plano, Texas, USA; ‡Private Practice, Oral and Maxillofacial Surgery; Director, Santa Rosa
Maxillofacial Surgery Center, Caracas, Venezuela; §Professor, Department of Orthodontics, Baylor College of
Dentistry – The Texas A & M University System Health Science Center, Dallas, Texas, USA; ¶Professor, Associate
Director, Illizarov Research Program, Texas Scottish Rite Hospital for Children, Dallas, Texas, USA

SUMMARY. The purpose of this study was to analyse the skeletal changes and stability of the distracted
segments during and after simultaneous widening and bilateral lengthening of the mandible in baboons with a
miniaturized intraoral bone-borne osteodistractor. Distraction appliances were activated 5 days after vertical
posterior body and midsymphyseal osteotomies at a rate of 0.9 mm/day for 10 days. The appliances were then
stabilized for a period of 8 weeks, after which the animals were killed. The distraction gaps and gingival tissues
were studied clinically and on standardized radiographs. The proportional movement of the distracted
segments that we found supports the clinical use of the miniaturized intraoral bone-borne distraction appliance
to widen and lengthen the mandible selectively. It also supports the concept of positioning the mandibular
osteodistractors parallel to the common vector of distraction, which should parallel the corrected maxillary
occlusal plane. © 2001 The British Association of Oral and Maxillofacial Surgeons

INTRODUCTION stability in a large animal model have not to our knowl-

The hallmarks of treatment of anterior–posterior and
transverse mandibular deficiency by compensatory ortho-
dontics, functional appliances or orthopaedic devices are
instability, damage to the periodontium, and compro-
mised facial aesthetics.1–7 New approaches and surgical
techniques have been developed to widen and lengthen
the mandible simultaneously at an early age and facilitate
efficient orthodontic treatment without extractions.8–15
Using distraction osteogenesis techniques based on
sound biological principles, adolescents and adults with
mandibular deficiencies can benefit from surgically
assisted mandibular widening and lengthening and ortho-
dontic treatment without extractions.13,16–20 Proper plan-
ning for predictable distraction osteogenesis depends on
knowledge of the positional changes of the mandible and
the subsequent stability of the repositioned jaw.
Despite the fact that surgical techniques and distraction
technology have been continually evolving, widespread
application has awaited the development of a new
miniaturized intraoral osteodistraction appliance, which
has the capacity to widen and lengthen the mandible.
Although such an appliance has been developed and the
biological foundation for distraction osteogenesis has
been extensively studied, the positional changes and
169
edge been investigated. This report describes such a study.
We hypothesized: that the intraoral bone-borne osteodis-
traction appliance would simultaneously lengthen and
widen the mandibular segments as planned after osteo-
tomies of the vertical posterior body and symphysis, and
that the repositioned mandible would be stable.
MATERIALS AND METHODS
Six adolescent (3–4 years of age) Papio anubis baboons,
weighing 20–25 kg, were used as the experimental model.
Five animals underwent simultaneous bilateral mandibu-
lar lengthening and midsymphyseal widening using
miniaturized intraoral bone-borne osteodistractors. The
housing, care, and experimental protocol were in accor-
dance with guidelines established by Baylor College of
Dentistry Institutional Animal Care and Use Committee.
Distraction appliance
The bone-borne Dynaform® Intraoral Distractor (Stryker
Leibinger Inc.) was made of stainless steel and consisted
of a central body connected to four flexible arms. The
body of the appliance contained a 12-mm threaded rod,
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170 British Journal of Oral and Maxillofacial Surgery
one complete revolution of which produced 0.45 mm of
distraction. The terminal ends of each arm were fork-
shaped to engage the titanium positional bicortical bone
screws.
Surgical techniques
All surgical procedures were done under general endo-
tracheal anaesthesia. The animals were premedicated
with ketamine hydrochloride (10 mg/kg) and xylazine
(1.2 mg/kg). Anaesthesia was induced with ketamine
hydrochloride (5.0 mg/kg) and maintained with 2% iso-
iflurane. Vital signs were monitored and maintained
within a normal physiological range.
Midsymphyseal osteotomy
To prevent interference during widening, the maxillary
canines were reduced to the level of the occlusal plane
using standard pulp capping procedures. A 3 cm horizon-
tal incision was made 4–6 mm labial to the depth of the
mandibular vestibule through the orbicularis oris mus-
cle. After the muscle had been transsected, the dissection
was directed obliquely, posteriorly, and inferiorly
through the mentalis muscle until it made contact with
the mandibular symphysis. The periosteum was reflected
inferiorly to the lower border of the mandible where a
small channel retractor was placed. Next, the soft tissue
between the mandibular central incisors was reflected
superiorly to the alveolar crest with minimal detachment
of the contiguous tissues. Four titanium bone markers
were placed in a quadrilateral configuration two on each
side of the planned osteotomy. A vertical osteotomy was
made through the midsymphysis of the mandible contin-
uing to the interdental space between the apices of the
mandibular incisors. Then, with a straight hand piece
and a surgical 701 bur, the cut was continued through the
labial cortical plate of the mandible to the alveolar crest.
The osteodistractor was adapted across the osteotomy
site by two superior and two inferior arms that were
fixed to the mandible with 2 mm bicortical screws.
The inferior arms of the appliance were placed sub-
mucosally and fixed directly to the mental symphysis;
the superior arms were fixed with transmucosal screws.
Once the distractor was attached to the bone, the incom-
pletely sectioned lingual cortex was fractured in half by
malleting and manipulating a spatula osteotome through
the superior osteotomy site. The appliance was activated
to achieve an immediate 2 mm separation of the bone
segments. The mucoperiosteal flap was repositioned and
the wound closed in layers.
Bilateral vertical posterior body osteotomy
A 3 cm mucosal incision was made over the external
oblique ridge, halfway up the ascending ramus and
extending inferiorly over the alveolar ridge to the area
opposite the first and second molars. A subperiosteal tun-
nelling dissection was used to expose the buccal cortex,
mandibular angle, and the alveolar ridge. The periosteum,
muscles, and soft tissue were detached sufficiently to
expose the planned osteotomy site. Four titanium bone
markers were placed, two on either side of the planned
osteotomy. The vertical posterior body osteotomy was
etched into the bone about 5 mm distal to the third molar
teeth. The osteotomy was made sequentially first by sec-
tioning the cortex of the inferior border of the mandible
extending the cut superiorly several millimetres into the
cancellous bone. Next, the reciprocating saw was reposi-
tioned laterally to section the buccal cortex obliquely.
With a periosteal elevator positioned on the lingual side of
the ramus to guard against lingual nerve injury, the saw
was placed upside down and the osteotomy was carried
through the alveolar crest superoinferiorly to within
3–4 mm of the inferior alveolar canal. Most of the ramus
had now been sectioned with the exception of a 4–5 mm
segment of bone medial to the inferior alveolar nerve and
the cancellous bone surrounding the alveolar canal.
The arms of the osteodistractor devices were con-
toured with wire-bending forceps to facilitate placement
of the arms with attached fork ends to either side of the
osteotomies. The posterior arms of the appliance were
placed submucosally and fixed to the segments of the
proximal ramus. Anteriorly, the appliance was fixed
transmucosally to the distal mandibular body segment in
the canine–bicuspid interspace. After the proximal and
distal segments had been fixed and stabilized bilaterally,
the incompletely sectioned lingual cortex was fractured
by malleting a spatula osteotome through the superior
osteotomy site. After completing the osteotomy, the
appliance was activated to achieve an immediate 2 mm
separation of the bony edges, to avoid premature consoli-
dation and make sure that the osteotomy was completed.
The mucoperiosteal flap was repositioned and main-
tained in place with horizontal mattress sutures.
Distraction protocol
In all animals the appliances were activated five days
postoperatively (latency period), at a rate of 0.9 mm/day
for 10 days. After distraction had been completed the
appliances were stabilized for the following 60 days
(consolidation period) at which time animals were killed
by exsanguination, and perfused with 10% buffered
formalin. The two anterior arms of each distraction
appliance were cut to facilitate removal of the distractor.
The positional fixation screws were retained in place.
Radiographic evaluation
Radiographs were taken in all animals preopera-
tively, immediately postoperatively, before the start of
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Positional changes and stability of bone segments during simultaneous bilateral mandibular lengthening 171

distraction, at the end of the distraction period, and superimposed tracing using the bone markers, appli-
every 14 days during the consolidation period. During ances, and anatomical landmarks.
the radiographic examinations, the mandible was held at The positional changes of the proximal segment were
a fixed distance against the X-ray cassette to minimize evaluated relative to the cranial segment. The positional
the error caused by magnification of projection. These changes of the distal segment were evaluated by com-
radiographs were used to analyse the positional changes paring its movements relative to the proximal segment
and stability of the repositioned segments. (Table 1).
Titanium bone markers (2 mm long and 0.5 in
diameter) were placed during the operation. Two pairs of
implants were placed bilaterally on both sides of the
osteotomy to identify the right and left sides on the later-
al cephalograms based on: distance (5 mm from the
osteotomy in the right side and 8 mm on the left), and
location (more inferior on the right side and more superi-
or on the left). These markers were used to evaluate posi-
tional changes of the distal mandibular segments relative
to the proximal segment. Another two pairs of implants
were placed in the supraorbital and zygomatic regions to
evaluate changes of the proximal segments relative to the
skull.21–22

Cephalometric procedures
Lateral and submental cephalometric radiographs were
A
taken with the mouth closed using a customized
Cephalostat. The lateral radiographs were exposed at an
object-to-tube distance of 152.5 cm with the object
against the film. The submental radiographs were taken
at 84 kVP and 100 mA with an exposure time of 1/24
second. Because of technical problems with the initial
submental radiograph of one animal, the data about the
transverse lane were collected from only four animals.

Lateral radiographs
For each lateral radiograph the following landmarks
were independently traced on film acetate (Fig. 1A & B):
discrete osseous components (endocranium, orbit, and
mandible); bone markers (one at the frontal bone, one at
the zygoma, two on either side of the osteotomy in the
mandibular posterior vertical body and two at the site of
the symphyseal osteotomy; bicortical screws; fork ends Fig. 1 (A) Lateral cephalogram. (B) Tracing of skeletal anatomy,
reference landmarks (1–6), titanium bone markers, and teeth from the
and distraction rod of the appliances; and mandibular lateral radiograph.
teeth (first molars, canines, and central incisors).
We used these landmarks as registration points when
Table 1 Sagittal plane positional changes, point definition, and
we superimposed serial head film tracings to calculate associated reference landmarks: lateral view
the amount and direction of movements. Three sets of
arbitrary horizontal reference landmarks, defined paral- Positional changes Point definition and reference landmarks
lel to the orientation of the distraction vector (distraction Amount of lengthening Linear changes (mm) between
rod), were drawn on the first tracing of each series. The (4) and (5)
reference landmarks (Fig. 1B) indicated the position of Rotation of distal Angular changes (⬚) between (3–4)
segment and (5–6)
the cranial segment (1 and 2), the proximal segment Horizontal and vertical Linear changes (mm) between (1–2)
(3 and 4), and the distal segment (5 and 6). Three sepa- movement of proximal and (3–4)
rate superimpositions were made on the metallic bone segment
Rotation of proximal Angular changes (⬚) between (1–2)
markers within each segment. Each segment was super- segment and (3–4)
imposed and its reference landmarks transferred to the
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172 British Journal of Oral and Maxillofacial Surgery

Submental radiographs RESULTS

For each submental radiograph the following anatomical
Each animal had a class I occlusion and normal trans-
structures and landmarks were traced (Fig. 2A & B):
verse proportion before operation. After distraction there
skeletal anatomy (condyles, foramen magnum, zygo-
was a class III canine and molar malocclusion with an
mas); bone markers (two on either side of the symphyeal
anterior and bilateral cross-bite. No animal had an ante-
osteotomy, two on either side of the mandibular osteoto-
rior or posterior open-bite. An asymmetric shifting of the
my); and bicortical screws.
mandible to the left was noted in one animal.
The reference landmarks (Fig. 2B) indicated the posi-
In all animals the soft tissue had healed without
tion of the anterior (7 and 8) and posterior (9 and 10)
detachment or tearing of the gingival cuff. Although there
portion of the distal segment, anterior part of the proxi-
was mild and transient inflammation of the crestal gingi-
mal segment (11 and 12), as well as the lateral (13 and
va and around all the transmucosally placed screws, there
16) and medial (14 and 15) aspects of the condyles.
was no evidence of soft tissue infection throughout the
These were identified on the first tracing and transferred
duration of the experiment. Most of the screws remained
to the subsequent tracings after superimposition.
stable throughout the study. Only three bicortical screws
Landmarks on the distal segment described transverse
in the superior arms of the symphyseal area became
positional changes of its anterior and posterior aspects.
slightly loose during the consolidation period. These
Rotation of the distal segments characterized by the
12 mm bicortical screws, however, continued to maintain
anterior and posterior aspects of the proximal segments
the appliances in place after secondary tightening.
was also evaluated, as well as rotation of the condyles
All positional changes were analysed in the sagittal and
(Table 2).
transverse planes during the distraction period (positional
changes between radiographs taken immediately postop-
eratively and at the end of the distraction period) and
consolidation period (positional changes occurred
between the radiographs taken at the end of the distraction

Fig. 2 (A) Submental cephalogram. (B) Tracing of skeletal anatomy, reference landmarks (7–16), titanium bone markers, and teeth traced from the
submental radiograph.
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Positional changes and stability of bone segments during simultaneous bilateral mandibular lengthening 173

Table 2 Transverse plane positional changes, point definition, and Table 3 Positional changes of the proximal segment: lateral view
associated reference landmarks: submental view
Animal Distraction period
Positional changes Point definition and reference landmarks
Angular Vertical Horizontal (mm) Angular (⬚)
Amount of widening Linear changes (mm) between (7) and (8) (⬚) (mm) Anterior
Width of posterior distal Linear changes (mm) between (9) and (10)
segment Anterior Posterior
Angle of distal segment Angular changes (⬚) between (7–9) and
(8–10) 1 94.2 97.3 94.8 ;1.6 92.4
Width of anterior Linear changes (mm) between (11) 2 91.3 91.7 91.0 ;2.3 ;5.8
proximal segment and (12) 3 ;0.2 91.9 92.0 ;2.5 97.1
Intercondylar width Linear changes (mm) between (14) 4 ;7.2 91.7 94.6 ;0.2 97.9
and (15) 5 ;2.7 91.6 93.1 93.2 90.5
Intercondylar angle Angular changes (⬚) between (13–14) and Mean ;0.9 92.8 93.1 ;0.7 94.8
(15–16)
;:downward and backward linear translation and forward rotation;
9:upward and forward linear translation and backward rotation.

Table 4 Positional changes of the distal segment: lateral view

Animal Distraction period Consolidation period

Distraction Angular Distraction Angular

(mm) (⬚) (mm) (º)

1 ;4.3 ;11.9 ;0.9 92.0

2 ;7.5 ;1.8 ;0.6 ;2.5
3 ;7.1 ;5.5 ;2.6 ;5.3
4 ;8.8 92.9 ;0.8 ;7.6
5 ;9.6 ;4.4 ;2.7 0
Mean ;7.5 ;4.1 ;1.5 2.7
;:forward linear translation and downward rotation; 9:backward
linear translation and upward rotation.

period and at the end of the consolidation period before

and after necropsy (Fig. 3A & B; Fig. 4A & B).

Positional changes in the sagittal plane

Proximal segment
During the distraction period the proximal segment
moved superiorly in all five animals (Table 3). In four
cases this segment also moved slightly anteriorly, while
one animal showed 3.2 m posterior repositioning.
Angular changes of the proximal segment also occurred
in all five baboons. In two animals the proximal segment
rotated forward while in the other three animals it
moved backwards, resulting in a mean backward rota-
tion of only 0.9⬚ (Fig. 3A).
During the consolidation period, the proximal seg-
ment of all five animals consistently moved anteriorly.
In four of these animals this anterior movement was
combined with forward rotation, while the proximal
fragment in one animal rotated backwards 5.8⬚. Changes
in the vertical position varied, and were related to the
B
amount of rotation (Fig. 3B).

Fig. 3 (A) Positional changes of the proximal and distal segments in Distal segment
the sagittal plane during the distraction period. (B) Positional changes
of the proximal and distal segments in the sagittal plane during the During the distraction period the distal segment moved
consolidation period. anteriorly, producing a 7.5 mm mean increase in the
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174 British Journal of Oral and Maxillofacial Surgery

Fig. 4 (A) Positional changes of the proximal and distal segments in the transverse plane during the distraction period. (B) Positional changes of
the proximal and distal segments in the transverse plane during the distraction period.

Table 5 Positional changes of the proximal segment: submental view

Animal Distraction period Consolidation period

Anterior width Intercondylar Intercondylar Anterior width Intercondylar Intercondylar

(mm) width (mm) angle (⬚) (mm) width (mm) angle (⬚)

1 ;7.0 94.0 ;25.1 95.4 94.6 97.2

2 ;1.2 98.9 ;10.0 91.3 91.6 ;18.9
3 ;1.5 96.5 ;16.4 91.0 ;1.9 ;17.4
4 95.3 91.6 ;10.2 90.7 92.6 90.6
Mean ;1.1 95.3 ;15.4 92.1 1.4 7.1
;:increase in linear and angular translation; 9:decrease in linear and angular translation.

length of the mandible (Table 4). The distal segment
rotated backwards in four animals relative to the proxi-
mal segment, while one baboon had a 2.9⬚ forward rota-
tion (Fig. 3A).
During the consolidation period, there was a slight
anterior movement in three of the animals, while the
remaining animals had an increase in mandibular length.
In terms of rotation, the distal segment was stable in
one baboon, rotated forward in another animal, and
rotated backwards in the remaining three animals
(Fig. 3B).
Positional changes in the transverse plane
Proximal segment
During the distraction period the intercondylar distance
decreased in all animals. These linear positional changes
were always combined with increased intercondylar
angulation, but the amount of condylar rotation varied
(Table 5). In three of four baboons the anterior width of
the proximal segment also increased, while in one ani-
mal the anterior ends of the proximal segment moved
towards each other (Fig. 4A).
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Positional changes and stability of bone segments during simultaneous bilateral mandibular lengthening
During the consolidation period the anterior width of
the proximal segment decreased slightly in all animals.
In two, this movement was combined with a decrease in
the intercondylar angle. The intercondylar distance of
the other two animals increased further with simultane-
ous increases of the intercondylar angle (Fig. 4B).
Distal segment
The anterior width of the distal segment increased
during the distraction period (Table 6). The distance
between the posterior aspects of the distal segment also
increased in three animals and decreased in one. The
angle between left and right halves of the distal segment
decreased in three and increased slightly in one (Fig. 4A).
The anterior width of the distal segment remained
stable during the consolidation period in all baboons. In
contrast, the posterior width decreased slightly in three
animals. One of these also had an increase of the angle
between the two halves of the distal segment. The angu-
lar changes were minimal in the other animals (Fig. 4B).
DISCUSSION
Successful surgical correction of mandibular deformities
depends on many factors including three-dimensional
anatomy, severity of the deformity, the positions of asso-
ciated structures, muscular tension, the magnitude of
movement, and the stability of the fixation systems and
correct distraction vector.23–25 Many studies have
analysed repositioning of bone segments in orthognathic
surgery,26 but the three-dimensional positional changes
of the distracted segments during gradual simultaneous
widening and bilateral lengthening of the mandible
using a bone-borne intraoral appliance in a large animal
model has not to our knowledge been described.
The results of our study showed that the proximal and
distal segments underwent variable complex three-
dimensional translational and rotational movements.
Although secondary movements of the segments during
the consolidation period were possible, and potentially
related to instability of the screws, this was considered
unlikely. Indeed, our histological investigations consis-
tently showed that there was intimate contact between
the screws and bone.27 These findings are similar to
those seen in osseointegration.
During the distraction period the proximal segments
of all five animals moved superiorly and slightly anteri-
orly (Fig. 3A). Rotational changes of the proximal seg-
ment were inconsistent. The same type of movement
patterns have been described for unfavourable angle
mandibular fractures, and may be explained by the influ-
ence of the musculature involved.28 There are several
solutions to minimize the problematic displacements of
the proximal segment that we noted during distraction.
175
First, the position of the proximal segment could be
maintained by an interdental mandibular osteotomy,
which preserves the occlusion between lower and upper
molars. Such an osteotomy, however, may be indicated
only for cases where there is adequate space between the
roots and where there are no tooth buds at the level of
the osteotomy. Secondly, osteotomies are positioned
anteriorly to the pterygoid–masseter muscle sling.
Interestingly, we observed little superior translation of
the proximal segments after similar distraction proce-
dures in clinical practice. Patients’ compliance (sensory
feedback, inability to generate large forces) or differ-
ences in muscle size and strength compared with those
of the baboons are possible explanations.
In the transverse plane the intercondylar distance was
reduced and the intercondylar angle increased in all five
animals. The condylar rotation and the medial reduction
of the intercondylar distance may have been the result of
the biomechanical effect of the mandibular widening
movement,29 the medial pterygoid muscle effect on
these segments, or the positional changes reported dur-
ing mandibular fractures, or a combination.28 Our previ-
ous investigation showed histological changes in the
condyle during mandibular widening.30 This suggests
that condylar rotation, if not compensated for, could
create inappropriate loading on the articular surface of
the condyle and subsequent reactive changes. The sever-
ity of the histological changes in the fibrous and carti-
laginous layers has been correlated with the direction of
rotational forces at the condyles.30
Rotational displacement of the condyles during
mandibular widening can be compensated for by incor-
porating a hinge mechanism in the distraction appliance
for mandibular lengthening that is parallel to the axis of
the distraction vector to minimize lateral displacement
of the proximal segment.31 Because the human mandible
is less tapered and smaller than that of the baboon, less
condylar rotation, and therefore fewer degenerative
changes, might be expected.32
The amount of anterior distraction displacement of
the distal segment during the distraction period varied
between 7.1 mm and 9.6 mm, and was associated with a
slight downward rotation relative to the proximal seg-
ment. Although not all of the lengthening occurred dur-
ing the distraction period, the overall amount of
mandibular lengthening (distraction and consolidation)
was equal to the amount of activation of the frame
(9 mm). The variation between animals may be attrib-
uted to radiographic geometry, angular translation of the
bone segments and associated bone markers, or instabili-
ty of the appliance. One animal had only 4.3 mm of
mandibular lengthening combined with considerable
(11.9⬚) downward rotation of the distal segment as a
result of an intraoperative complication. The sagittal
osteotomy done on this animal resulted in accidental
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176 British Journal of Oral and Maxillofacial Surgery
Table 6 Positional changes of the distal segment: submental view
Animal Distraction period
Anterior Posterior Angular
(mm) (mm) (º)
1 ;7.9 ;8.1 90.2
2 ;7.2 ;3.2 ;3.7
3 ;9.1 ;0.3 ;7.1
4 ;7.9 95.9 ;12.2
Mean ;8.0 ;1.4 ;5.7
;:increase in linear and angular translation; 9:decrease in linear
and angular translation.
fixation of the distal and proximal segments by one
bicortical screw. The downward rotation of the distal
segment may be related to the tension of suprahyoid
muscle,6,20 the fixation system of the appliance (fork end
type) or bending of the arms.
The variability of the amount of widening may also
be explained biomechanically.29 Typically, linear mandi-
bular osteodistractors are oriented parallel to the
mandibular body and fixed to the bone with positional or
lag screws. This may have adverse biomechanical
effects during bilateral mandibular lengthening with or
without simultaneous widening of the symphysis.
Distractors that are attached parallel to the longitudinal
axis (mechanical) of the mandibular body may cause
lateral displacement of the proximal bone segments
combined with rotation of the condyles.29
In the transverse plane, the anterior width of the
mandible increased 7.2–9.1 mm during the distraction,
decreasing the mandibular arch angle between 3.7⬚ and
12.2⬚. The angular decreases were not proportional to the
amount of symphyseal mandibular widening. Changes in
the distance between the posterior aspects of the distal
segment were small and similar to the changes between
the anterior aspects of the proximal segment. Again, the
amount of mandibular widening was not always equal to
the amount of expansion of the frame, which may have
been produced by the biomechanical narrowing effect of
distraction devices placed parallel to the mandibular
body during simultaneous lengthening and widening.
These support the mechanical concepts previously illus-
trated by computer models.29 When the distraction
device is oriented parallel to the body of the mandible, as
in this study, it will tend to produce lateral displacement
of the anterior ends of the proximal segment and have a
narrowing effect in the symphyseal area.
During the consolidation period positional changes of
the proximal segment in the sagittal plane were generally
oriented anteriorly, which may be related to forward rota-
tion of the segment. These changes may again be related
to the tension of the masticatory muscles. If so, this
suggests that the muscles have distinctly different influ-
ences during the distraction and consolidation periods.
The 1.5 mm anterior translation of the distal segment dur-
ing consolidation may be the result of residual distraction
forces, which were not dissipated during distraction.33–35
Anterior In the transverse plane the anterior width of the distal seg-
(mm)
ment remained stable during the consolidation period in
90.8 all baboons. Continuous increase in the intercondylar
90.2 distance, combined with further increase in the inter-
;0.7
90.2
condylar angle, was seen in half the animals. Positional
90.1
changes of the posterior ends of the distal segment were
proportional to those which occurred between the distal
ends of the proximal segment.
Lengthening and widening distraction gaps remained
relatively stable, indicating that the small intraoral
osteodistraction appliances were strong enough to main-
tain the stability of the repositioned bone segments and
prevent anteroposterior relapse. On the other hand, con-
tinuous condylar rotation and downward rotation of the
distal segment indicates undesirable forces, which were
probably produced by bent distraction appliances (spring
effect) because they were oriented parallel to the body
of the mandible. The arms of the distraction device had
to be considerably longer in the baboon model than in
the human because of the length of the mandible. The
shorter human mandible allows shorter arms to mini-
mize such potentially undesirable effects.
In this baboon model an ideal occlusion was converted
to Class III occlusion with bilateral cross-bite and poor
intercuspation. No occlusal adjustments were made.
Clinically, however, the amount of distraction can be
regulated (increased or decreased) by positional changes
of the bone segments to achieve the desired occlusion.
In clinical practice either orthodontic appliances or train-
ing elastics could be used to control or guide the final
positioning of the bone segments. Occlusal control with
means other than mandibular function is particularly
prevalent in children. Orthodontics can fine-tune the
occlusal details after the stabilization period.
Judicious use of class II elastics may be indicated both
during the distraction and consolidation periods to pre-
vent reciprocal forces affecting the temporomandibular
joints.36 The advantage of the relatively short-term use of
Class II training elastics to unload the temporomandibu-
lar joints must be considered in the total rehabilitation
strategy. Long-term use of poorly monitored Class II
elastics may contribute to a compromised, under-corrected
Class II malocclusion, which could make a secondary
reconstructive surgical correction essential.
Considerations of the experimental model
Central to the evolution of predictable distraction osteo-
genesis remains the development of more sophisticated,
miniaturized intraoral appliances with the ability to grad-
ually distract and manipulate the mandible. The need to
develop and analyse the use of such an appliance for use
BJOM-114.QXD 5/15/01 10:52 AM Page 177
Positional changes and stability of bone segments during simultaneous bilateral mandibular lengthening
in humans prompted our search for a large primate model
such as an adolescent baboon that is anatomically, mor-
phologically, and biologically similar to humans.
In addition, the biomechanical measure of what
strength was required by the appliance to distract the
mandible was unknown. The design of this study using a
baboon animal model with powerful masticatory mus-
cles37 attempted to mimic simultaneous widening and
lengthening of the mandible in humans. Despite the
important positional changes, which created large Class III
malocclusions with cross-bite, the relatively simple dis-
traction appliance provided adequate stability for the
simultaneous lengthening and widening of the mandible.
The animals tolerated, and adapted to, the distraction
appliances and occlusal changes.
Biomechanical considerations
Success with such a technique to reposition the anterior
part of the mandible is dependent on manipulating the dis-
traction callus before the interzone ossifies. Radiographic
analysis of the distraction gap at the end of the distraction
period and at the beginning of the consolidaton period typi-
cally showed a central radiolucent interzone surrounded by
newly formed bone trabeculae emanating from the edges
of the distracted segments. At this stage the interzone is
occupied by extensible collagen fibres. The shape of the
distraction regenerate can be changed by anterior traction
or by digital manipulation of the mechanically weak callus.
The window of opportunity for such change is relatively
short, between two and three weeks after distraction.
Another way to correct anterior open bite is acute
secondary repositioning of the distractor to achieve a
more desirable distraction vector. Such secondary re-
positioning may be accomplished under a local anaesthe-
sia by bending the arms of the appliance and, therefore,
modifying the orientation of the distraction rod.
In the current study the osteodistractor rods were
placed parallel to the maxillary occlusal plane in most of
the animals. This orientation of distraction appliances
produced little open-bite during bilateral mandibular
lengthening. The position of the Dynaform® Intraoral
Distractor was decided before the operation with the aid
of cephalometric radiographs and dental models. In one
animal the mandibular movement was inferior and ante-
rior, which caused an increase in the lower anterior
facial height. The achievement of the desired occlusion
without open-bite in most of the animals gives strong
support to the use of this distraction protocol.
Patients with mandibular deficiency have mandibles
that are frequently three-dimensionally small and retro-
positioned. To achieve a mandible of normal size and
anatomy, complex three-dimensional movements are nec-
essary. Successful use of unidirectional distractors in
these cases means that the appliance must be positioned
177
correctly at the time of the operation. Precise preplanning
that takes account of the biomechanical effect of appli-
ance orientation is paramount for predictable widening
and lengthening of the mandible.
The vertical and sagittal orientation of the distraction
rod can be defined preoperatively by the use of cephalo-
metric prediction studies that simulate mandibular
movement parallel to the planned distraction vector
(usually parallel to the maxillary occlusal plane). Gateno
and Teichgraeber have developed a method of computer-
ized preoperative planning of the distraction process.38
Simulation of the distraction process using a virtual dis-
tractor allows the establishment of the ideal position and
orientation of the distraction appliance to accomplish the
desired final mandibular lengthening. With the develop-
ment of such high-technology computer programs to
simulate three-dimensional positional changes of the
mandible, predictable distraction osteogenesis is poised
to make great strides in the future.
The present study has obvious limitations that affect
its predictive value. The sample size is limited. Future
prospective long-term longitudinal studies are necessary
to evaluate precisely the changes after distraction and
stability after removal of the osteodistractors, at the end
of the stabilization period. These studies must be done
using more predictable and repeatable placement of
osteodistraction appliances that are consistent with the
planned distraction vectors. The use of axial computed
tomograms and stereolithographic models together with
cephalometric planning studies will facilitate these goals
of proper vector planning. Despite the limitations of
such in investigation, this is the first study of simultane-
ous symphyseal expansion and mandibular lengthening
in primates that has shown good skeletal stability over
the relatively short period of follow-up.
ACKNOWLEDGEMENTS
We thank Alexander M. Cherkashin MD, Priscilla R. Gillaspie LATG,
E. Gerald Hill LATG, Andrea L. Lavender, and Pearl B. Kapuscinski
MS for their help and support; and Stryker-Leibinger Inc, the Oral and
Maxillofacial Surgery Foundation, and the Distraction Osteogenesis
Foundation for support. These investigations were a part of studies that
were the basis of an MS degree awarded by Baylor College of
Dentistry–The Texas A&M University System Health Science Center.
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The Authors
Marianela Gonzalez DDS, MS
Oral Surgeon, Santa Rosa Maxillofacial Surgery Center
Caracas, Venezuela
William H. Bell DDS
Private Practice, Oral and Maxillofacial Surgery
Plano, Texas
César A. Guerrero DDS
Private Practice, Oral and Maxillofacial Surgery;
Director
Santa Rosa Maxillofacial Surgery Center
Caracas, Venezuela
Peter H. Buschang PhD
Professor, Department of Orthodontics
Baylor College of Dentistry–The Texas A & M University System
Health Science Center
Dallas, Texas, USA
Mikhail L. Samchukov MD
Professor and Associate Director, Illizarov Research Program
Texas Scottish Rite Hospital for Children
Dallas, Texas, USA
Correspondence and requests for offprints to: Professor W. H. Bell,
4100 15th Street Suite 104, Plano, TX 75093, USA. Tel: +1 972 596
8767; Fax: ;1 972 867 7041; E-mail: whbell2000@aol.com
Accepted 2 March 2001