Distraction Osteogenesis of the Mandible

[SmallJaw12]

So I was just looking up videos on jaw surgery and came across this-
https://www.smbalaji.com/jawline-correction-surgery-using-internal-distraction/amp/ and
https://www.smbalaji.com/jawline-correction-mandibular-distraction-for-sleep-apnea/amp/
The patient in the second link had a MMA surgery before this, but didn't see an improvement in his sleep apnea.
The distraction seems to be on the ramus though, doesn't this make the result dependent on the occlusional plane? This won't be a good option for someone with a steep occlusional plane right?
And advancing the length of the ramus by 16 mm or 18 mm seems a bit too much. Wonder what the effect on the condyles would be.
Also why is distraction osteogenesis for the mandible not popular?

[SMSOMS]

Distraction was popularized in the late 1990"s when Paul Tessier claimed it would be the end of traditional jaw surgery.  The problem is it is incredibly inaccurate, can leave unsightly scars on the face and it very painful and slow.  It is ideal for Pierre-Robin Sequence and our group has distracted babies with airway issues as a result of mandibular hypoplasia as young as 7 days old.  Adults do not tolerate it and frankly there are other ways to more accurately and expeditiously lengthen the ramus and mandibular body if indicated. 

[SmallJaw12]

Thanks for your views @SMSOMS. What are the methods for advancing the ramus without distraction though? Don't the normal osteotomies only work on the mandibular body? Also, how does distraction osteogenesis done on babies hold up in the long run? Is it as inaccurate as doing it on adults? And is the new bone generated of the same quality as the normal bone or is it thinner/weaker?

[GJ]

Yeah, I keep praying distraction will become the gold standard, but it seems to never make progress. Lack of research/funding?

[SMSOMS]

The ramus can be lengthened via an inverted "L" osteotomy and to a lesser degree by a "C" osteotomy of the ramus but they require bone grafting of the defects.  The resultant bony construct from distraction is histologically the same as other bone but depending on circumstance might be of a slightly smaller dimension.  Keep in mind babies that are distracted do not have teeth so the dental occlusion is not a factor and thus may be  inaccurate so it does not matter.  Children are actively growing bone throughout into their late teens so they have that in their favor.  Adults grow bone in response the the osteotomies only and at the site of the osteotomies.  Children do things we only wish adults could do!!   Distraction has been heavily researched and frankly tortures patients.  Have seen lots of it I would never want it for myself or family if conventional surgery was an option

[triple_banker]

The ramus can be lengthened via an inverted "L" osteotomy and to a lesser degree by a "C" osteotomy

I have read that the masseter muscle can't be lengthened so what would happen to the muscle when the ramus is lengthened? A problem with implants lengthening the gonial angle is the risk of disrupting the pterygomasseteric sling which results in the muscle to retract superiorly. Would this be a problem with ramus osteotomies as well?

[SMSOMS]

We lengthen the ramus every time a patient undergoes a TJR for progressive condylar resorption (ICR) and the masseter muscle is re-approximated to the medial pterygoid or directly to the mandible without any issue.  The happens with an inverted "L" if done percutaneously.  The reality is that those who treat ICR with an inverted "L" or BSSO tend to get either all body lengthening (BSSO) of a bit of body and ramus lengthening(inverted"L). The problem with this is it is a camouflage as the problem is pure ramus shortening

The big issue with gonial implants is the overlying muscle can on occasion cause resorption of bone under it or even deposition of bone over them. I have never been a fan of doing them for those reasons

[kavan]

So I was just looking up videos on jaw surgery and came across this-
https://www.smbalaji.com/jawline-correction-surgery-using-internal-distraction/amp/ and
https://www.smbalaji.com/jawline-correction-mandibular-distraction-for-sleep-apnea/amp/
The patient in the second link had a MMA surgery before this, but didn't see an improvement in his sleep apnea.
The distraction seems to be on the ramus though, doesn't this make the result dependent on the occlusional plane? This won't be a good option for someone with a steep occlusional plane right?
And advancing the length of the ramus by 16 mm or 18 mm seems a bit too much. Wonder what the effect on the condyles would be.
Also why is distraction osteogenesis for the mandible not popular?

First link:

The WORDS of the site you linked to convey the patient got a significant improvement with the distraction. The VIDEO just shows them removing the distraction device. Did it not occur to you they did not back up their words with an actual side by side before/after photo comparison?

Second link:

They only show an after skull but not the before. The after jaw bone is all scalloped and bumpy.  I bet the soft tissue contour would be a scalloped jaw line to reflect the outcome of the distraction.

No surprise why the outfit promoting this as way to achieve large advancements for adults OPTED OUT of showing before and after photos.

[SmallJaw12]

@Kavan, in hindsight, yes, it's suspicious that they aren't showing the afters properly. I'd created this topic because this was the first time I'd heard about DO and lengthening of ramus and had a few queries about it.

[Suchislife]

I've looked up quite a bit about distraction osteogenesis of the mandible. I have also consulted with a max fax surgeon who has done MANY DOs on children and adults.


This topic keeps coming up on this forum and I mean it does seem great/the wonderful future when you first come across it. Let me however give you the low down:

Yes, jaw distraction is a novel treatment that can potentially be suitable for patients aged between 0-45 and might be preferred over DJS in some unique cases.

In saying this, DO in adults will almost always need to be followed up by a traditional bsso/lefort. This latter DJS is needed to realign the bite as the DO results are not precise or predictable and very few surgeons who are experienced in DO will rely on it alone to fix a bite or advance a jaw. DO is most suitable when a patient needs a very large movement that cannot easily/stably be achieved by traditional DJS alone. E.g. 20+mm. In those cases, they will distract for the initial distance, wait for healing, and then do a traditional bsso+lefort.