ORIGINAL ARTICLE

New Technique for Mandibular Symphyseal Distraction

by a Double-Level Anchorage and Fixation System:
Advantages and Results
Franco Carlino, MD, DDS, Giuseppe Pantaleo, DDS,y Fabio Ciuffolo, DMD,z
Pier Paolo Claudio, MD, PhD,§ and Antonio Cortese, MD, DDSjj

histogenesis with augmentation of both bone and soft tissue.

Introduction: A surgical technique to widen the mandible is the
Bone-borne distraction will result in more stable results; dental-
mandibular midline distraction: the most common indications for
borne devices will result in more simple and aesthetically rewarding
mandibular midline distraction are severe mandibular anterior
procedures. Hybrid techniques usually show mixed results
crowding, severe mandibular transverse deficiency, uni- or bilateral
depending on the characteristics of the device. For this reason
crossbite, impacted anterior teeth with inadequate space, and tipped
we developed a combination of both the aforementioned systems
teeth. Commonly used distraction devices can be divided into 2
which is not a hybrid system but the combination of an immediate
systems: bone-borne distraction system appliance, dental-borne
expansion of the symphysis and fixation by 1 miniplate with only 2
distraction systems. Each system has peculiar advantages, disad-
screws acting like hinges during distraction, combined with a
vantages, and different indications. To combine advantages of both
lingual distraction system at the alveolar bone level.
systems we developed a new technique adopting an immediate
Conclusions: Bone-borne distraction systems result in more
basal bone widening with fixation after osteotomy and a dental
efficient basal bone mandibular widening with increased stability
borne rigid lingual system for distraction.
for dental results. For dental-borne appliance the advantages consist
Aim: The aim of this work is to show a new technique for
in no second surgery need for their removal, no transmucosal
symphysis mandibular distraction based on a double-level
hardware emergence and better aesthetic, especially when
anchorage and fixation system on clinical patients showing final
lingual devices were used. Our technique combines advantages
results and advantages.
of both procedures.
Methods: Two patients affected by dento-alveolar and basal bone
maxillary and mandibular transversal collapse even in association
with other skeletal malocclusion were selected. Patients were Key Words: Bone-borne distraction, dental-borne distraction,
clinically and radiographically studied and analyzed at different mandibular midline distraction, skeletal malocclusion, symphyseal
times before and after surgery. Dental and basal bone measurements distraction
were performed clinically and radiographically. (J Craniofac Surg 2016;27: 1469–1475)
Results: The results were optimal with perfect dental arches
alignment followed by closing of the open bites with multiple-
segmented surgery in a second surgical time. No misalignment of
the 2 mandibular halves was noticed during the distraction
U sually, the treatment of arch length and width discrepancies has
been managed with orthodontic treatment and extraction of
teeth.1 Transverse mandibular and maxillary deficiencies and crowd-
procedure. ing of the anterior teeth are frequently seen in orthodontic patients.2
Discussion: Dental-bone discrepancies correction is mandatory At the age of 1, the mandibular symphysis is fused and orthodontic
before orthodontic treatment alignment. Transversal jaw devices cannot be used to open it during therapies.3 Herberger4 and
expansion can be achieved safely and stably by distraction of Housley et al5 showed how the orthodontic treatment can achieve a
both maxillae for the combination of osteogenesis and high relapse rate of dental alignment, after dental arch lengthening
and widening at long-term period, combined or not with dental
extractions. Alexander et al6 demonstrated that another approach
From the Casa di Cura Villa dei Pini, Department of Surgery, Section of could be possible for mandible widening with a vertical symphysis
Maxillofacial Surgery, Civitanova Marche; yDepartment of Neuro- osteotomy, rotating the hemimandible segments laterally with or
sciences, Reproductive and Odontostomatological Sciences, University without using a bone graft. A surgical technique to widen the
of Naples Federico II, Naples; zPrivate Practice, Città Sant’Angelo, mandible is the mandibular midline distraction (MMD), also
Italy; §Department of Radiation Oncology, Department of BioMolecular described under various names, such as: mandibular symphyseal
Sciences, University of Mississippi, Oxford, MS; and jjDepartment of
Medicine and Surgery, Unit of Maxillofacial Surgery, University of
distraction osteogenesis, transmandibular symphyseal distraction
Salerno, Salerno, Italy. (osteogenesis), and mandibular midline osteo-distraction. The most
Received December 28, 2015. common indications for MMD are severe mandibular anterior crowd-
Accepted for publication April 9, 2016. ing,7 severe mandibular transverse deficiency, uni or bilateral cross-
Address correspondence and reprint requests to Pier Paolo Claudio, MD, bite, impacted anterior teeth with inadequate space, and tipped
PhD, Department of Radiation Oncology, University of Mississippi, teeth.8,9 Other possible indications can be reconstruction of the
Jackson, MS 39126; E-mail: [email protected] mandible after trauma,10 v-shaped mandible with anterior tissue
The authors report no conflicts of interest. deficiency,1,11 hypoglossia-hypodactyly syndrome,12 Nager syn-
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275 drome and 18p-syndrome.13 For maxillo-mandibular relationship,
DOI: 10.1097/SCS.0000000000002831 mandibular arch form and mandibular intercanine width often restrict

The Journal of Craniofacial Surgery  Volume 27, Number 6, September 2016 1469
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Carlino et al The Journal of Craniofacial Surgery  Volume 27, Number 6, September 2016

the amount of maxillary expansion causing large buccal corri- disorders that contraindicated oral surgery. Orthodontic appliances
dors.14,15 Commonly used distraction devices can be divided into were applied before surgery avoiding orthodontic alignment at this
2 systems: bone borne distraction system appliance, dental borne phase. Spaces were orthodontically created between the roots of
distraction systems. Each system has peculiar advantages and dis- incisors on both arches. Mandibular distraction was performed
advantages. Bone-borne distraction systems will result in more under general anesthesia via naso-tracheal intubation. Buccal
efficient basal bone mandibular widening with increased stability mucosa incision was performed on the upper maxilla from 15 to
for dental results.16,17 Disadvantages of this system are the necessity 25 followed by the traditional technique for SARPE. At the lower
of a second surgery stage for appliance removal and encumbrance in jaw a mucosa incision was performed from 32 to 42 in a more buccal
the aesthetic frontal area with also hardware trans-mucosal emer- fashion to leave sufficient amount of mucosa and muscle tissue for
gence.18 Advantages of dental borne appliance consist in no need for proper suture. Periosteal elevation was performed up to the inferior
second surgery removal, no trans-mucosal hardware emergence, and border of the mandible on the lower side and up to the alveolar bone
better aesthetic especially when lingual devices are used.19,20 Dis- on the upper side. Symphysiotomy was performed using a thin
advantages consist in larger expansion amount at dental level in rotating bur from the lower border up to the alveolar bone level
comparison to basal bone level resulting in theoretically more risks avoiding periosteal elevation at the fixed mucosa level and on the
for dental crowding relapse.21 With both systems stability and vector lingual side. In this way, bone fragment nourishment particularly at
distraction control are still a challenge because of the strong masti- the alveolar bone level was preserved. Complete osteotomy was
catory muscles insertions on both sides of the mandibular arch with carried out at the bone level with thin chisels to avoid interdental
high forces application in masticatory cycles, which is impossible to bone septum damage. With this technique also we avoided the risks
avoid in postdistraction and retention periods.22,23 To combine of bone fragment exposure at the osteotomy site (Fig. 1). Following
advantages of both bone-borne and dental-borne systems, we devel- symphysis osteotomy, an immediate bone widening to the extent
oped a new technique adopting an immediate basal bone widening needed was performed and a first level of fixation was applied at the
and fixation after osteotomy and a dental borne rigid system on the basal bone area by a single 3 holes mini plate and only 2 screws
lingual side for distraction. The aim of this work was to show the acting like hinges. Second step was the appliance at the dental level
procedure sequences and clinical results of this new technique for of the distraction anchorage system on first molars and first pre-
symphyseal mandibular distraction based on a double-level ancho- molars connected to a lingual jack screw to achieve an aesthetic and
rage and fixation system. Results obtained so far with the advantages efficient distraction system combining advantages of both bone-
of this new procedure are discussed. borne and dental-borne appliance commonly used for mandibular
distraction. At the lower border level immediate bone widening was
METHODS possible because of the intrinsic regenerative properties of this
In this study, we selected adult patients over 18 years of age affected mandibular bone area. Stability was sufficient because of the
by dento-alveolar maxillary and mandibular transversal collapse combination of the mini plate at the lower border with the
even in association with other skeletal malocclusion. Patients with anchorages of the dental level distraction system with its intrinsic
systemic or psychological disorders that contraindicate oral surgery rigidity able to resist to the masticatory forces. At the alveolar level
were excluded from the study; also neoplastic pathologies or precise positioning of the 2 bone fragments was achieved using a
previous treatment with bisphosphonate drugs were considered very stable and rigid appliance compound of 4 bands on first molars
excluding factors. From the study were also excluded patients and premolars casted with the arms of an orthodontic jack screw
whom underwent other surgical procedures except surgical assisted positioned on the lingual side. This system increases mandibular
rapid palatal expansion (SARPE), bilateral sagittal split osteotomy, transversal dimension by rotating the 2 mandibular halves in a
genioplasty, Le Fort I osteotomy. All surgeries were performed by transversal direction up to the desired dimension for an optimal final
the same surgeon (Franco Carlino). All patients were informed result. Therefore, the treatment sequence consists in a first surgical
about the study protocol and surgical risks; a written consent was stage with symphyseal osteotomy and mandibular base widening to
obtained in all patients explaining alternatives, advantages, and
disadvantage of the surgical intervention. The study was conducted
in accordance with the ethical principles provided by the Declara-
tion of Helsinki and the principles of good clinical practice, under
the IRB protocol number 38/06. Patients were analyzed preopera-
tively before orthodontic appliance positioning (T0), preoperatively
after orthodontic appliance positioning before teeth alignment (T1),
after surgery before distraction (T2), after distraction before teeth
alignment (T3), after orthodontic teeth alignment (T4), 1 year after
surgery (T5). Patients were studied by X-ray orthopantomography,
X-ray cephalograms in lateral-frontal and -axial view and finally
dental model measurements at T0, T1, T2, T3, T4, and T5. Dental
measurements were performed on buccal mesial cusps transversal
distance of first molars, first premolars, and canines. Measurements
on X-ray cephalograms in frontal view were performed on the
transversal distance of the lateral polar condyle, gonion and anti-
gonion points at times T0, T4, T5, avoiding X-ray exposure at T1,
T2, T3. Pictures of the face and occlusal view at both lateral and
frontal views of the patient were taken at T0, T1, T2, T3, T4, and T5.
FIGURE 1. Surgical technique: (A) the mandibular base is widened for the
Surgical Technique necessary amount. (B) Distraction screw is activated the following week, the 2
Two patients were selected for this new technique. The surgery bone screws act as hinges. (C) The mandible is thus widened at the alveolar
was not performed in patients with systemic or psychological ridge level.

1470 # 2016 Mutaz B. Habal, MD

Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 27, Number 6, September 2016 Mandibular Symphyseal Distraction

achieve the necessary dimension. A second surgical stage consists

in distraction by orthodontic jackscrew activation after setting the
device on the first premolars and molars on the lingual side. The 2
bone screws used for fixation of the mini plate at the basal bone
level act like hinges. The distraction procedures followed the most
common protocols: 1 week latency followed by active distraction
phase at 1 mm/day divided into 2 activations every day for the
amount of time needed to achieve the desired final result. Retention
time was 3 months long with the distraction device in place and
contemporary early start of orthodontic treatment for dental arch
alignment. Therefore, the third step consists in orthodontic align-
ment of the widened mandible after distraction at the alveolar ridge
level. No need of a second-step surgery for hardware removal was
necessary because there is no trans-mucosal hardware in this
system. Following this technique 2 surgical patients with bimax-
FIGURE 3. Patient 1: (A, B) spaces have been orthodontically created between
illary dental crowding and transversal collapse in association with roots of central incisors in both arches. (C, D) Orthodontic expansion screws
other skeletal discrepancies were performed. have been applied on 4 bands devices in both arches.

Patient 1
A 30-year-old patient was referred to our Department for a class dislocation. Dental arches were then orthodontically aligned
II malocclusion with skeletal open bite transversal collapse and (Fig. 5). Finally, a multisegment bimaxillary osteotomy was per-
crowding of both maxilla and dental arches (Fig. 2). The patient’s formed for definitive correction of the skeletal malocclusion with
past medical and social history were noncontributory, and he had open bite closure. Optimal regeneration of the alveolar bone at the
good oral hygiene. Spaces between central incisors roots were osteotomy site was achieved as documented by postdistraction
created on both arches by orthodontic treatment before surgery. orthopantomography and periodontal probing at 6 months
Distraction devices comprehensive of orthodontic expansion screws after surgery.
with their arms casted with 4 bands were applied on both dental
arches at palatal and lingual sides (Fig. 3). Patient 2
Under general anesthesia a traditional maxillary surgically Patient 2 was a 26-year-old patient referred to our Department
assisted expansion was performed. In the mandible a vertical affected by hyperdivergent skeletal open bite with bimaxillary
symphysis osteotomy was conducted between roots incisors by a dental arch crowding and transversal collapse (Fig. 6). The patient’s
lower buccal incision without touching the gingiva at the alveolar past medical and social history were noncontributory, and he had
and lingual sides. The 2 mandibular halves were intentionally good oral hygiene. Orthodontic jackscrew was casted with 4 bands
opened to the final required wideness at basal bone level; con- on first molars and first premolars. Osteotomies were performed for
versely, the dental-borne distractor achieved a precise bone contact surgical assisted maxillary expansion on the upper jaws and another
at the alveolar bone level. The 2 halves were fixed with the orthodontic jackscrew casted with 4 bands on first molars and
miniplate at the lower mandibular border with only 1 screw on premolars was set on the lingual side of the mandibular arch.
each side (Fig. 4). Because space was detected only between the 41 and 42 roots,
Jackscrews activation allowed maxillary distraction for the mandibular symphysiotomy was performed in a ‘‘z’’ fashion to
upper jaw and contemporary mandibular transversal distraction safely perform distraction. Mandibular basal bone was immediately
by lateral rotation of the 2 mandibular halves with hinges on the widened up to the final amount needed and fixed with 3-hole mini
2 bone screws. At the mandibular level the combination of the 2 plates with only 2 screws (Fig. 7). At the alveolar bone level precise
basal bone and dental borne systems allowed a transversal con- bone contact was achieved to obtain alveolar bone preservation
trolled expansion avoiding unwanted mandibular halves

FIGURE 4. Patient 1: (A) a traditional maxillary surgical expansion is performed.

(B) In the mandible a vertical symphysis osteotomy is performed. (C) The 2
FIGURE 2. Patient 1 before surgery: (A) class II malocclusion, (B) open bite, (C) mandibular halves are intentionally opened to final wideness at their base, they
both arches crowded and transversally collapsed, (D) anterior overjet. are fixed with a mini-plate on their lower border, with only 1 screw on each side.

# 2016 Mutaz B. Habal, MD 1471

Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Carlino et al The Journal of Craniofacial Surgery  Volume 27, Number 6, September 2016

FIGURE 6. Patient 2 before surgery: (A, B) bimaxillary crowding and transversal

collapse, (C) hyperdivergent skeletal open-bite.

progressively toward the posterior region due to the effect of

anterior space closure with anterior transversal distance reduction
by the orthodontic treatment. At basal bone level we achieved an
immediate increase of the transversal diameters, due to the sym-
physiotomy, which remained unchanged in the second phase after
dento-alveolar distractor activation. Increase was recorded only for
dento-alveolar transversal diameters because of the rotation of the 2
hemi-mandibles around the axis of the symphyseal fixation screws
FIGURE 5. Patient 1: (A) after distraction in frontal view; (B) after dental acting as pins. With this modality of distraction no condylar
alignment and spaces closure in frontal view; (C) after dental alignment and diameters increase was obtained, thus avoiding any risk of dysfunc-
spaces closure in lateral view; (D) after multisegmented bimaxillary surgery and
open bite closure in lateral view; (E, F) dental arches final alignment; (G) post- tional symptoms for the temporomandibular joints. In fact, a
treatment x-ray orthopantomography image. constant distance between the 2 condyles (external polar points
of the condyles) was reported before and after treatment.

during distraction. Screw activation started after 1-week latency DISCUSSION

after surgery. Distraction procedure followed common protocol at
Transversal mandibular and maxillary constrictions are often
1-millimeter rate per day divided into 2 activations for the time
associated with other skeletal discrepancies and malocclusion with
needed to achieve a proper occlusion and the space required for
anterior teeth crowding. In these conditions high rate of relapse is
correct dental arch alignment. Distraction widened the 2 mandibular
expected for dental alignment obtained by orthodontic treatment
halves by a rotating movement with the hinges at the 2 fixation
screws on the basal symphyseal level. The 2 jaws were widened at
the same time followed by jackscrew fixation for a retention time of
3 months for both jaws. Orthodontic alignment of the 2 dental
arches was performed after the 3 months of retention time up to full
alignment. Definitive correction of the malocclusion was performed
at a second surgical stage by bimaxillary multisegment osteotomy
plus genioplasty (Fig. 8).

RESULTS
The results were optimal with perfect arches alignment and closing
of the open bites with multiple-segmented surgery in a second
surgical time. There were no complications, and the transversal
increase was made both by basal bone (immediately at the first
surgical time) and by osteo-distraction with dental bone distractor at
alveolar bone level. No relapses were reported after 1 year. Details
of the dental and X-ray measurements are reported in Table 1. No
misalignment of the 2 mandibular halves was noticed during the
distraction procedure.
There was a considerable improvement of the aesthetics of the FIGURE 7. Patient 2: (A) maxillary teeth borne distractor; (B) osteotomy for
maxillary surgical expansion; (C) symphysiotomy performed in a ‘‘Z’’ fashion;
smile with the disappearance of black corridors. In both patients at (D) screw activation widens the alveolar process, with hinge on the 2 fixation
the dental level we achieved a greater range of expansion screws.

1472 # 2016 Mutaz B. Habal, MD

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The Journal of Craniofacial Surgery  Volume 27, Number 6, September 2016 Mandibular Symphyseal Distraction

after orthodontic alignment; main disadvantages consist in aesthetic

encumbrance in the frontal area of the smile, trans-mucosal hard-
ware emergence, and second surgery for their removal.18 On the
other side, dental borne devices are commonly considered more
effective on teeth level transversal expansion with theoretically
more risks for dental crowding relapse. Advantages for this kind of
technique consist in better aesthetic preservation in the frontal area
of the smile particularly for lingual devices, no hardware emergence
through the mucosa and no need for a second surgery step for
appliance removal.16,17,29 Hybrid techniques usually show mixed
results depending on the characteristics of the device. Another
important and unsolved problem concerns stability of the system
and full control of the distractor vectors during active expansion in
relation to the strong forces applied to the system during mastica-
tory cycles impossible to avoid during distraction and retention
time.22,23,30 Our original technique is designed to achieve all the
advantages of both bone-borne and teeth-borne techniques without
FIGURE 8. Patient 2: (A) after distraction in lateral view; (B) after
any corresponding disadvantages. For this reason, we developed a
multisegmented surgery in lateral view showing open bite closure; (C, D) combination of both the aforementioned systems which is not an
dental arches final alignment. hybrid system (affected anyway by some disadvantages and limits),
but the combination of an immediate symphysis expansion and
fixation by 1 miniplate with only 2 screws acting like hinges during
alone without basal bone surgery.9,24 Also, the quality and the distraction combined with a distraction system at the alveolar bone
aesthetic result of the orthodontic treatment is related to the level (Fig. 1). This second dental-borne system allowed precise
correction of the basal bone discrepancy, especially in the mandible contact between the 2 mandibular halves at the alveolar bone level,
because of the thin width of the alveolar bone.5 Orthodontic teeth full control of the stability and the distraction vectors during active
alignment in crowded dental arches showing dental-bone discre- and consolidation periods by its intrinsic rigidity for the 4 bands on
pancy often results in periodontal damage, aesthetic smile decline first molars and premolars casted with an orthodontic jack-
for incisors proinclination, and finally relapse.1,25 For these reasons screw.16,21 In this way precise distraction was possible at the
dental-bone discrepancies correction is mandatory before ortho- alveolar bone level without any septum bone loss as confirmed
dontic treatment alignment.16 Transversal jaw expansion can be by postoperative X-ray orthopanoramic. Because of the combi-
achieved safely and stably by distraction of both maxillae for the nation of immediate bone expansion and fixation at the basal bone
combination of osteogenesis and histogenesis with augmentation of level and distraction at the alveolar bone level by a dental-borne
both bone and soft tissues. SARPE procedure is a very common and distractor on the lingual side, no need of a second surgery for
well-documented technique;26 MMD on the other side is a less appliance removal and no aesthetic decay at the frontal smile area
common and documented procedure with different and less stan- was present. Stability of the basal bone and dental arches expansion
dardized techniques showing advantages and disadvantages in and of the dental alignment were detected and confirmed at 1-year
relation to the surgeon choice.27 Commonly devices for transversal controls. These results are very meaningful in relation to the other
mandibular distraction are classified in dental borne devices, bone reported results achieved with other common MMD with related
borne and hybrid systems. Each system has its own characteristics problems and complications.13,14,23 As stated from articles review
and qualities from systematic review in the literature.28 Bone-borne about MMD survey, different problems and complication may arise
systems are considered more effective at the basal bone level with in each technique.7 Appliance-related problems are mostly seen in
the advantage of theoretically less relapse rate for dental crowding bone-borne distractors showing infection around the osteosynthesis

TABLE 1. Dental Measurements of Selected Patients at T0 (Preoperatively Before Orthodontic Appliance Positioning), T1 (Preoperatively After Orthodontic Appliance
Positioning Before Teeth Alignment), T2 (After Surgery Before Distraction), T3 (After Distraction Before Teeth Alignment), T4 (After Orthodontic Teeth Alignment), and
T5 (1 Yr After Surgery)

Interpremolar Interpremolar Interpremolar Interpremolar Intermolar Intermolar Mesio

Intercanine Lingual/First Buccal/First Lingual/Second Buccal/Second Mesiolingual/First Buccal/First
(mm) Premolars (mm) Premolars (mm) Premolars (mm) Premolars (mm) Molars (mm) Molars (mm)

Patient 1 T0:24 T0:24 T0:30 T0:22 T0:28 T0:33 T0:42

T1: 24 T1: 24 T1: 30 T1: 22 T1: 28 T1: 33 T1: 42
T2:24 T2:24 T2:30 T2:22 T2:28 T2:33 T2:42
T3: 26 T3: 29 T3: 35 T3:27 T3: 33 T3: 40 T3: 50
T4:27 T4:29 T4:35 T4:28 T4:34 T4:40 T4:50
T5:27 T5:29 T5:35 T5:28 T5:34 T5:40 T5:50
Patient 2 T0:26 T0:26 T0:32 T0:27 T0:34 T0:28 T0:38
T1: 26 T1: 26 T1: 32 T1: 27 T1: 34 T1: 28 T1: 38
T2:26 T2:26 T2:32 T2:27 T2:34 T2:28 T2:38
T3: 26 T3: 28 T3: 33 T3: 30 T3: 38 T3: 33 T3: 42
T4:25 T4:28 T4:33 T4:31 T4:39 T4:33 T4:42
T5:25 T5:28 T5:33 T5:31 T5:39 T5:33 T5:42

# 2016 Mutaz B. Habal, MD 1473

Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Carlino et al The Journal of Craniofacial Surgery  Volume 27, Number 6, September 2016

and some breakage of the appliance.11,31 Also soft tissue lesions are basal bone allowing immediate bone expansion of the symphysis
most commonly seen in distraction bone borne and hybrid appli- in combination with precise positioning of the bone fragments at the
ances consisting in sores of oral mucosa and lips.31,32 In the first of bone alveolar level, thereby avoiding septum damage. System
our patients mild gingival recession was noticed for central lower stiffness results in full control of the distraction vectors with full
incisors related to orthodontic treatment movements because post- satisfactory and stable final result. Aesthetic of the smile was
operative integrity of bone septum at the osteotomy site was preserved during treatment by using a lingual dental-borne device
preserved as shown in X-ray orthopantomography after distraction and avoiding second surgery need for appliance removal.
(Fig. 5G).
Other complications may arise both by tooth-borne and bone-
borne distractors use related to teeth vitality, root exposure, and REFERENCES
deep pockets.31,33,34 Surgical problems are reported in the literature 1. Proffit WR, White RP, Sarver DM. Contemporary Treatment of
concerning the damage of the mental nerve in complete osteotomy Dentofacial Deformity. St Louis, MO: Mosby; 2003
and wound dehiscence. Regarding cranio-maxillary disorders they 2. Guerrero CA, Bell WH, Gonzalez M, et al. Intraoral distraction
are reported in some articles, but symptoms were transient and osteogenesis. In: Fonseca RJ, ed. Oral and Maxillofacial Surgery, vol.
resolved without any additional therapy.33,34 None of these pro- 2. Philadelphia, PA: W.B: Saunders Company; 2000:367–371
blems and complications were detected in our patients except for 3. Sperber GH. Craniofacial Development. Hamilton, BC: Decker Inc;
gingival recessions probably related to orthodontic treatment 2001
because of septum integrity as confirmed by control x-ray at the 4. Herberger RJ. Stability of mandibular intercuspid width after long
osteotomy site at 1 year after surgery. However, because the sample periods of retention. Angle Orthod 1981;51:78–83
5. Housley JA, Nanda RS, Currier GF, et al. Stability of transverse
size of our report is limited to 2 patients, this is a limitation on the expansion in the mandibular arch. Am J Orthod Dentofacial Orthop
possible future complications and therefore more patients need to 2003;124:288–293
be studied. 6. Alexander CD, Bloomquist DS, Wallen TR. Stability of mandibular
Gingival recession was not related to the distraction technique constriction with a symphyseal osteotomy. Am J Orthod Dentofacial
but to common orthodontic treatment complications; long-term Orthop 1993;103:15–23
result was favorable after orthodontic appliance removal and better 7. Guerrero CA, Bell WH, Contasti GI, et al. Mandibular widening by
oral hygiene care. intraoral distraction osteogenesis. Br J Oral Maxillofac Surg
To avoid possible complication particular care must be taken in 1997;35:383–392
orthodontic treatment for frontal teeth roots at the osteotomy site 8. Duran I, Malkoc S, Iseri H, et al. Microscopic evaluation of mandibular
symphyseal distraction osteogenesis. Angle Orthod 2006;76:369–374
before surgery to avoid septum damage during drilling. At surgery 9. King JW, Wallace JC. Unilateral Brodie bite treated with distraction
time thin drill use and precise bone contact of the alveolar bone at osteogenesis. Am J Orthod Dentofacial Orthop 2004;125:500–509
the osteotomy site is recommended; in this way, it is possible to 10. Niederhagen B, Braumann B, Berge S, et al. Tooth-borne distraction to
avoid any alveolar septum damage at the osteotomy site as con- widen the mandible. Technical note. Int J Oral Maxillofac Surg
firmed by postoperative X-ray (Fig. 5G). To avoid gingival reces- 2000;29:27–28
sion of lower frontal teeth, general recommendation, as in every 11. Alkan A, Ozer M, Bas B, et al. Mandibular symphyseal distraction
orthodontic treatment, is to avoid extensive dental movements and osteogenesis: review of three techniques. Int J Oral Maxillofac Surg
ensuring a good oral hygiene. 2007;36:111–117
In accordance with the literature a small significant anterior 12. Kita H, Kochi S, Yamada A, et al. Mandibular widening by distraction
osteogenesis in the treatment of a constricted mandible and telescopic
movement of the anterior frontal teeth has been noticed in our bite. Cleft Palate Craniofac J 2004;41:664–673
patients.35– 37 Because of the main aesthetic request from ortho- 13. Kessler P, Wiltfang J, Merten HA, et al. Distraction osteogenesis of the
dontic patients, particular important for our patients was the mandible in craniofacial abnormalities. Mund Kiefer Gesichtschir
improvement of the aesthetic appearance of the smile and the face 2000;4:178–182
after MMD and following bimaxillary osteotomy because of black 14. Uhde MD, Sadowsky C, BeGole EA. Long-term stability of dental
corridors disappearance, frontal teeth alignment, and dental arches relationships after orthodontic treatment. Angle Orthod 1983;53:240–
enlargement. Mandatory for our young adult patients was the 252
absence of hardware appliance in the aesthetic frontal area of the 15. Burke SP, Silveira AM, Goldsmith LJ, et al. A meta-analysis of
mandibular intercanine width in treatment and postretention. Angle
smile during the entire treatment.
Orthod 1998;68:53–60
16. Cortese A, Savastano G, Amato M, et al. New palatal distraction device
CONCLUSIONS by both bone-borne and tooth-borne force application in a paramedian
Bone-borne distraction systems resulted in more efficient basal bone anchorage site: surgical and occlusal considerations on clinical
bone mandibular widening with increased stability for dental cases. J Craniofac Surg 2014;25:589–595
17. Cortese A, Savastano G, Amato M, et al. Intraoral epimucosal fixation
results. Disadvantages of this system are the necessity of a second
for reducible maxillary fractures of the jaws; surgical considerations in
surgery stage for appliance removal and the encumbrance in the comparison to current techniques. J Craniofac Surg 2014;25:2184–2187
aesthetic frontal area with trans-mucosal emerging hardware. Den- 18. Seeberger R, Abe-Nickler D, Hoffmann J, et al. One-stage tooth-borne
tal-borne appliance advantages consist in no second surgery need distraction versus two stage bone-borne distraction in surgically assisted
for removal, no trans-mucosal emerging hardware, and better maxillary expansion (SARME). Oral Surg Oral Med Oral Pathol Oral
aesthetics especially when lingual devices are used. Disadvantages Radiol 2015;120:693–698
consist in larger expansion amount at dental level in comparison to 19. Nada RM, van Loon B, Schols JG, et al. Volumetric changes of the nose
basal bone level resulting in theoretically more risks for dental and nasal airway 2 years after tooth-borne bone-borne assisted rapid
crowding relapse. With our original technique a combination of the maxillary expansion. Eur J Oral Sci 2013;121:450–456
advantages of both dental and bone-borne procedures was achieved 20. Cortese A, Pantaleo G, Amato M, et al. Chin wing osteotomy for
bilateral goldnhar syndrome treated by ‘‘chin wing mentoplasty’’:
by immediate expansion at the basal bone level combined with aesthetic, functional, and histological considerations. J Craniofac Surg
dento-alveolar tooth-borne distraction on 4 teeth on the lingual side. 2015;26:162
Complete bone regeneration was possible by this double-level 21. Cortese A, Savastano M, Savastano G, et al. One-step transversal palatal
original technique for the intrinsic regenerative abilities of the distraction and maxillary repositioning: technical considerations,

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Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 27, Number 6, September 2016 Mandibular Symphyseal Distraction

advantages, and long-term stability. J Craniofac Surg 2011;22:1714– expansion appliances. Am J Orthod Dentofacial Orthop 2015;148:97–
1719 109
22. Zhao SF, Tang EY, Hu QG, et al. Treatment of postoperative midfacial 30. Gunbay T, Akay MC, Aras A, et al. Effects of transmandibular
deformity of chilopalatognathus by distraction osteogenesis with a self- symphyseal distraction on teeth, bone, and temporomandibular joint. J
constructed tooth-borne distraction device. J Craniofac Surg Oral Maxillofac Surg 2009;67:2254–2265
2014;25:1028–1032 31. Mommaerts MY, Spaey YJ, Soares Correia PE, et al. Morbidity
23. El-Bialy TH, Razdolsky Y, Kravitz ND, et al. Long-term results of related to transmandibular distraction osteogenesis for patients with
bilateral mandibular distraction osteogenesis using an intraoral tooth- developmental deformities. J Craniomaxillofac Surg 2008;36:
borne device in adult Class II patients. Int J Oral Maxillofac Surg 192–197
2013;42:1446–1453 32. Uckan S, Guler N, Arman A, et al. Mandibular midline distraction using
24. King JW, Wallace JC, Winter DL, et al. Long-term skeletal and dental a simple device. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
stability of mandibular symphyseal distraction osteogenesis with a 2006;101:711–717
hybrid distractor. Am J Orthod Dentofacial Orthop 2012;141:60–70 33. Kewitt GF, Van Sickels JE. Long-term effect of mandibular midline
25. Jung SK, Kim TW. Treatment of unilateral posterior crossbite with distraction osteogenesis on the status of the temporomandibular joint,
facial asymmetry in a female patient with transverse discrepancy. Am J teeth, periodontal structures, and neurosensory function. J Oral
Orthod Dentofacial Orthop 2015;148:154–164 Maxillofac Surg 1999;57:1419–1425
26. Sygouros A, Motro M, Ugurlu F, et al. Surgically assisted rapid 34. Raoul G, Wojcik T, Ferri J. Outcome of mandibular symphyseal
maxillary expansion: cone-beam computed tomography evaluation of distraction osteogenesis with bone-borne devices. J Craniofac Surg
different surgical techniques and their effects on the maxillary 2009;20:488–493
dentoskeletal complex. Am J Orthod Dentofacial Orthop 35. Basciftci FA, Korkmaz HH, Iseri H, et al. Biomechanical evaluation of
2014;146:748–757 mandibular midline distraction osteogenesis by using the finite element
27. Nadjmi N, Stevens S, Van Erum R. Mandibular midline distraction using method. Am J Orthod Dentofacial Orthop 2004;125:706–715
a tooth-borne device and a minimally invasive surgical procedure. Int J 36. Mommaerts MY, Polsbroek R, Santler G, et al. Anterior
Oral Maxillofac Surg 2015;44:452–454 transmandibular osteodistraction: clinical and model observations. J
28. de Gijt JP, Vervoorn K, Wolvius EB, et al. Mandibular midline distraction: Craniomaxillofac Surg 2005;33:318–325
a systematic review. J Craniomaxillofac Surg 2012;40:248–260 37. Gunbay T, Akay MC, Aras A, et al. Effects of transmandibular
29. Gunyuz Toklu M, Germec-Cakan D, Tozlu M. Periodontal, symphyseal distraction on teeth, bone, and temporomandibular joint. J
dentoalveolar, and skeletal effects of tooth-borne and tooth-bone-borne Oral Maxillofac Surg 2009;67:2254–2265

# 2016 Mutaz B. Habal, MD 1475

Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.