J. Maxillofac. Oral Surg.

https://doi.org/10.1007/s12663-020-01414-y

INVITED REVIEW

Distraction Osteogenesis Versus Orthognathic Surgery:

Demystifying Differences in Concepts, Techniques and Outcomes
Manikandhan Ramanathan1 • Godwin Alex Kiruba1 • Amelia Christabel2 •
Anantanarayanan Parameswaran1 • Sanjanaa Kapoor1 • Hermann F. Sailer3

Received: 15 June 2020 / Accepted: 1 July 2020

Ó The Association of Oral and Maxillofacial Surgeons of India 2020

Abstract Keywords Distraction osteogenesis
Orthognathic

Introduction The popularity and interest evoked by surgery
Concepts of distraction ostetogenesis
Concepts
orthognathic surgery and distraction osteogenesis are of orthognathic surgery
Distraction osteogenesis versus
undisputed in the field of oral and maxillofacial surgery. orthognathic surgery
However, questions regarding the individual identities of
either of them with clarity in their concepts, techniques and
outcomes have remained unanswered. The aim of this Background for This Review
review is to shed light on these questions.
Methods This review is structured as a narrative review of In the United States of America, there were about a hun-
thirty years of literature available in the specialities of dred thousand patients operated for orthognathic surgery
orthognathic surgery and distraction osteogenesis. within a timespan of 9 years [1]. Since the first published
Conclusion The authors present a review of existing lit- case of Orthognathic surgery in 1849 [2] and the first report
erature combined with contrasting experience gained over of Distraction osteogenesis in humans in 1992 [3], these
the years in providing an overview of the merits and surgical techniques have evolved significantly in many
demerits of the two surgical techniques which will aid the ways.
clinician in justifying the use of one technique over the Precious et al. [4] remarks that, ‘‘Orthognathic surgery
other. consists of a constellation of procedures that permit dif-
ferential alteration and repositioning of bone, cartilage,
& Manikandhan Ramanathan
muscle, teeth, gingiva, mucosa, and skin’’, while distrac-
drmaniramanathan@gmail.com tion osteogenesis is described as a biologic process of new
Godwin Alex Kiruba
bone formation between the surfaces of bone segments that
dr.god_alba@yahoo.com are gradually separated by incremental traction [5].
Amelia Christabel
About 18 years ago, the first publication on the long-
ameliachristabel@gmail.com term results of distraction osteogenesis was published by
Anantanarayanan Parameswaran
McCarthy et al. [6], in which he elucidated his 11-year
anantparam@gmail.com experience with mandibular distraction osteogenesis and
Sanjanaa Kapoor
summarized that it produced clinically favourable results.
kapoorsanjanaa@gmail.com Later, Shaw et al. [7] did a critical appraisal of 88 studies
Hermann F. Sailer
on distraction osteogenesis and found that almost all pub-
info@sailerclinic.com lications were based on retrospective studies, with short-
term evaluation of a limited samples from heterogeneous
1
Department of Oral and Maxillofacial Surgery, Meenakshi patient populations, lacking controls. He proposed the need
Ammal Dental College and Hospital, Chennai, India
for a prospective registry, for objective distraction osteo-
2
University of Ilinois, Chicago, IL, USA genesis research.
3
Klinik Professor Sailer, Zurich, Switzerland

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Distraction osteogenesis (DO) and orthognathic surgery pre-operatively to reduce operative time. There are no
(OGS) have been widely indicated in many deformities of patient-specific or customized distractors that have been
the craniofacial region. However, there still is great developed.
uncertainty as to which is the ideal choice of correction, Radiographs like orthopantomograms, lateral cephalo-
especially in terms of clinical indications, patient-related grams and postero-anterior cephalograms suffice in the
outcomes, such as stability, long-term influence on growth, treatment planning for orthognathic surgeries, unless the
socio-psychological implications and quality of life. This procedure is planned with computer-aided design/com-
also needs to be studied with variations in satisfaction and puter-aided manufacturing (CAD/CAM) technology to
social support among different ethnic groups [8]. Given the fabricate customized splints, cutting guides and patient-
lacunae in literature for well-designed clinical trials and specific implants (PSI).
publications with higher levels of evidence, we undertook Distraction osteogenesis doesn’t mandate complex vir-
this literature review to present a comprehensive report of tual pre-operative planning to simulate three-dimensional
how various parameters fare when comparing distraction (3D) movements, whereas in case of osteotomies that
osteogenesis and orthognathic surgery. This is a unique involve 3D movements of maxillomandibular complex,
literary review that undertakes a comprehensive compar- virtual planning software that incorporate DICOM data are
ison of pre-operative, intra-operative and post-operative commonly employed [19], in recent times.
parameters involved with both treatment modalities. The
aim is to present the plethora of evidence appraised Movements
regarding vital parameters to be considered prior to deci-
sion making between distraction osteogenesis and orthog- Quantum of Bone Movement
nathic surgery.
When an acute movement of bone is performed through
orthognathic surgeries, advancements of more than 7 mm
Pre-operative Planning are not advisable and those of more than 10 mm are con-
sidered to be with an elevated risk of relapse [20, 21]. The
Age lack of immediate adaptation of soft tissue envelope around
the new position of bone influences the stability by the
Distraction osteogenesis is versatile and can be performed stretch mechanisms and possible proprioceptive functions.
at any age, from neonates to adults as long as the patient is Movements of more than 7 mm, involving LeFort I or
physiologically capable to undergo surgery [9]. The com- higher-level advancements, have a propensity for non-
mon indication for neonatal mandibular distraction osteo- union and relapse, therefore, definitely warrant bone
genesis (MDO) is to ameliorate the difficulties encountered grafting to make them more stable and achieve primary
during breathing and feeding in patients with Pierre Robin healing [22–24].
sequence (PRS) [10–12] and Treacher Collins syndrome Distraction osteogenesis is a popular modality for larger
(TCS). Distraction osteogenesis has shown pre- advancements of 10 mm or more [25], as it remains rela-
dictable success in children and adolescents [13, 14] and tively stable [26]. In patients with syndromes or with cleft
can be safely performed even in older ages [15]. maxillary hypoplasia, who present with higher magnitude
Orthognathic surgeries are not performed in neonates of deficiencies, distraction osteogenesis is the preferred
and young children and are generally recommended only method of choice, due to excellent post-operative stability
after the skeletal growth completion occurs [16], as there [27–30] and the concomitant histogenesis [29], thereby
might be growth spurt variabilities, which will probably producing superior aesthetic and functional results.
necessitate future interventions. In rare instances, they may
be performed early. Prediction of Bone Movement

Pre-operative Imaging and Planning Vector control is crucial in the planning for distraction
osteogenesis [31], where the placement of the distractor
Distraction osteogenesis warrants computed tomographic dictates the primary vector. External distraction devices
(CT) scanning for pre-operative planning. CT scans offer flexible vector control and better predictability, when
divulge the finer details of the anatomic variations, which compared to internal devices, due to the ability of vector
allow proper planning of the vectors, aid in locating the change during the distraction period [11, 29, 32]. With
tooth buds, the inferior alveolar nerve, and also in assessing internal distractors, the vector is difficult to manoeuvre
the temporomandibular joint [17, 18]. Stereolithographic during distraction period, except for a few multi-vector
models can be fabricated and the distractors can be adapted internal distractors [33]. When moving large composite

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segments like LeFort II or III, the combined use of external growth centre deficits [14]. Hence, it can be used as an
and internal distractors is advised, for superior vector interim procedure to minimize the quantum of deformity,
control and stability after osteotomy. The activation of the providing a socially acceptable appearance.
distractor by 1 mm should ideally yield a movement of the Orthognathic surgery has limitations and cannot be used
same quantum. However, while external devices maintain as an interim procedure and is preferred after growth
higher accuracy of vectors in linear advancements, internal completion [38]. Osteotomies in the growing patients will
devices may induce rotational movements [34]. necessitate future interventions, as growth spurts would
Orthognathic surgery offers, in most instances, pre- produce changes in the final maxillomandibular
dictable movements through precise pre-operative planning relationship.
[4, 19] and intra-operative usage of splints to optimize the
bone position [35]. Shirota et al. published that a mean Composite Distraction Versus Multiple Osteotomies
error of \ 1.03 mm on the 3 axes was observed between
pre-operative simulation and post-operative CBCT images Multiple independent distraction of the bone segments in
with intra-operative navigation surgery [36], which suggest the naso-maxillary zygomatic complex aren’t commonly
that simulation-guided navigation makes accurate post- performed.
operative outcomes possible in orthognathic surgeries. Orthognathic surgery offers the possibility of move-
ments of the bone segments in the naso-maxillary zygo-
Directions of Bone Movement matic complex through simultaneous LeFort I and LeFort
III osteotomies, followed by fixation separately [39].
A major drawback of distraction is that impaction, setback
or compression of bone is not possible [37]. Calvarial Deformity Correction
Orthognathic surgery provides the possibility of bone
movements in multiple directions in space [27], including While correcting calvarial deformities in paediatric patients
retraction, and correction of discrepancies like vertical with osteotomies, there is an absolute necessity of inter-
maxillary excess [4]. vening bone/cartilage grafts and resorbable plates to be
used [40], as indicated in brachycephaly and
Three-Dimensional Bimaxillary Movements craniosynostosis.
Procedures like LeFort III distractions or frontoparietal
Kim et al. remarked that orthognathic surgery can offer (monobloc) distractions [41], negate the use of interposi-
complete movement of the entire maxillomandibular tional grafts. Posterior cranial vault distraction offers
complex, which acts as a rigid body with six degrees of considerable advantage over posterior vault osteotomies in
freedom in 3D space. The movements include translations craniosynostosis patients and the usage of internal,
in the anteroposterior, lateral, vertical directions and rota- resorbable distractors nullify the need for an additional
tions around the x-, y- and z-axes, commonly called the surgery [42].
pitch, roll and yaw rotations. They can be evaluated by a
3D surgical treatment objective (STO), which can be done Multiple Segmentations
precisely and as a single step through CAD/CAM tech-
nology [19]. Orthognathic surgery offers the possibility to address the
It is difficult to manipulate 3D movements of the max- segmental discrepancies of maxilla or midface, by sepa-
illomandibular complex, in a single stage through distrac- rating them into predetermined segments during surgery
tion osteogenesis [11, 29]. Multiple distractors may be used [27], and requires intricate planning and intra-operative
combined or sequentially; however, precise vector control splints.
may be challenging, as in facial asymmetry cases. Three or four pieces of segmentalization is not an option
while performing distraction osteogenesis [37], because
Surgical Procedures they will make the distraction segments unstable [33].

DO as Interim Procedure Obstructive Sleep Apnoea

Distraction osteogenesis can be used as a part of a staged Paediatric In severe forms of syndromic mandibular
surgical treatment plan to achieve early correction from deficiencies and maxillary hypoplasia, distraction osteo-
childhood, to minimize the deformities in patients with genesis is the initial modality of treating obstructive sleep
severe skeletal discrepancies [11, 29]. It does not induce apnoea (OSA) [11].
permanent growth in the regions of genetically determined

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In temporomandibular joint (TMJ) ankylosis, pre-re- tissues wherein the native periosteum had been destroyed
lease distraction has been advocated [43] to correct OSA [49].
for immediate airway improvement and better vector Orthognathic surgeries can be performed only in situa-
control of distal mandibular segment against stable proxi- tions, wherein there are no disruptions of periosteum and
mal ankylosed ramus component. with healthy soft tissue cover. Osteotomy cuts raise the risk
Orthognathic surgeries don’t have a role in paediatric of unfavourable fractures and bad splits in patients with
OSA management. low bone mineral density disorders like osteoporosis
[50, 51].
Adults Though maxillomandibular orthognathic rotation
advancements are mostly preferred for OSA correction, Condylar Hyperplasia/Hypertrophy
distraction of isolated mandible/maxillomandibular com-
plex is performed prior to ankylotic release similar to the Distraction osteogenesis has no role in managing situations
paediatric group. like condylar hypertrophy/hyperplasia, as it doesn’t influ-
ence the growth centre, which is actually the etiological
Transverse Skeletal and Dental Discrepancies factor. As mentioned earlier, distraction is futile when
impaction, reduction or compression movements are
Distraction osteogenesis is the best option for transverse required.
skeletal discrepancies, as it obviates the need for extrac- Surgical interventions for condylar hyperplasia either in
tions and proximal stripping, to gain space in the upper and isolation or with maxillomandibular osteotomies are the
lower arches [27] and to achieve facial fullness. treatment of choice in such pathologies at appropriate age
Orthognathic surgeries require transverse discrepancy [52].
management and space gain before surgery; hence,
extractions and proximal stripping play a vital role in Neo-condyle Rehabilitation
planning [44].
In patients with TMJ ankylosis, after resection of the
Segmental Defects ankylotic segment, reconstruction can be done with neo-
condyle distraction using the ramus segment [53]. Animal
Transport distraction osteogenesis offers the possibility of studies have demonstrated that the biomechanical proper-
reconstructing continuity defects of the maxillofacial ties of neo-condyle, under functional loading are equal to
region [45]. It can be achieved through incremental that of physiologic condyle. Histological analysis has
movement of one (bifocal distraction), two (trifocal dis- revealed the distraction gap filled with collagen fibrous
traction) or three (quadrifocal distraction) viable bone tissue gets gradually replaced by mature bone after 24
segments across a defect [46]. weeks postdistraction [54]. A pseudo-meniscus is formed
Orthognathic surgeries cannot replicate this movement by the fibrocartilaginous cap at the advancing front of
and are not indicated for bridging segmental defects. distraction, replicating a normal anatomic form.
Orthognathic surgery can also be employed as a
Irradiated Cases modality to achieve this by vertical sliding ramus osteo-
tomies, where the stump of the posterior ramus can replace
Distraction osteogenesis has been successfully performed the condyle [55]; however, there is no formation of a
in conditions with compromised vascularity like irradiated fibrocartilaginous cap which will act as a pseudo-meniscus.
mandibles. Confirmation of bone viability and the condi- Though there were reports of complete anatomic remod-
tion of surrounding soft tissues are vital parameters in elling and stable function, diminution of the angle was one
ensuring the success of distraction in irradiated cases [47]. disadvantage that was observed [56].
A conference abstract was the only mention of a
bimaxillary osteotomy performed for correction of Comparison of Costs
obstructive sleep apnoea, 2 years after radiation to the
mandible. They report no long-term results [48]. The procedure of distraction osteogenesis is more expen-
sive [4, 57] than orthognathic surgery, due to costs asso-
Compromised Bone Quality ciated with the distractors [28, 57] and the need for an
additional surgery to remove the distractor [37, 57, 58]. In
Bone regeneration has been observed after distraction our experience, we have observed that there is a need for a
osteogenesis, in suboptimal clinical situations like scarred longer stay in the hospital, for cases of transport distrac-
tion, which magnifies the cost.

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Single jaw or genioplasty surgeries are performed as day Osteotomy Design

care procedures, and hence, they cost considerably lower.
Bimaxillary surgery with ancillary procedures like bone Distraction osteogenesis involves linear bicortical osteot-
graft harvesting, necessitate a longer admission time when omy separation but it can also be performed in certain
compared to single jaw procedures [59]. However, this is instances with cortical scoring [12], like in neonatal dis-
only comparing surgical costs and not the need for pre/- traction of Pierre Robin sequence or Treacher Collins
post-operative orthodontics and possible functional appli- syndrome, to serve the purpose of emergency airway
ances over time. Recent advances like customized surgical improvement [10, 11].
guides, splints and patient-specific implants could con- In orthognathic surgery, specifically designed osteotomy
tribute to additional expenditure in orthognathic surgery. cuts are done, for complete mobilization and movement of
the osteotomized segments in different planes [24].
Training and Learning Curve For patients undergoing LeFort I distraction, there is no
necessity to down fracture the maxilla, but pterygo-max-
Surgeons who wish to master distraction osteogenesis illary dysjunction should be performed and the mobility of
techniques will realize that there is a learning curve asso- maxilla in anteroposterior direction should be achieved, to
ciated with it. While the technique and devices have check free movement of the distractors without any
undergone several changes over the years, it is imperative interference.
to have a thorough understanding of the process. This
learning process has evoked the need to modify the existing Bone Grafting
distraction devices and creating newer ones, for better
results with lesser complications [60]. To understand pae- As distraction osteogenesis eliminates the need for auto-
diatric distraction and its outcome, the patients would need genous bone harvesting and grafting at the site of bone
to be followed long term until growth cessation. movement [4, 29], there is no donor site morbidity
Orthognathic surgeries are still the workhorse for oral [9, 13, 64]. The only indication for bone grafting after
and maxillofacial surgeons and are in routine practice in distraction will be in cases of transverse deficiencies,
more centres around the world when compared to distrac- specifically in areas of mandibular ramus or zygoma, to
tion osteogenesis. This in turn may offer more opportuni- achieve optimal symmetry, if warranted.
ties for trainee surgeons to view them more frequently In orthognathic maxillary advancements of more than
when compared to DO. Newer advancements like virtual 7 mm, bone grafts are desirable to stabilize the osteoto-
3D pre-operative planning [61], which produces more mized segments [22–24]. This autogenous bone grafting
accurate results, might require additional training. has disadvantages like donor site morbidity, infection of
the bone graft, resorption and subsequent relapse due to
resorption [29]. Immediate bone grafting or the usage of
Intra-operative Factors synthetic substitutes for augmentation is an advantage of
OGS over DO, as fixation of those can be done
Anaesthetic Considerations simultaneously.

For placement of internal distractors, nasal intubation is Need for Overcorrection

preferred to prevent the interferences caused by the oral
endotracheal tube. For placement of extra oral distractors, For growing patients with facial asymmetry, who undergo
oral intubations can be practised. For distractor placement distraction, mild overcorrection of the segments is advised
in TMJ Ankylosis, fibre optic intubation is ideal, due to [65], to catch up with the growth of unaffected side and
lack of mouth opening and inability to visualize the vocal also to reduce the later discrepancies that might occur
cords [62]. during growth. In bilateral mandibular distraction, over-
Nasal intubation is preferred in orthognathic procedures correction to a skeletal class III maybe done to counter the
to facilitate the assessment of desired occlusion on table. future maxillary growth.
Certain centres report submental intubation for orthog- Overcorrection is not practised for orthognathic surgery
nathic surgeries, for better intra-operative assessment of patients, as they are operated after growth cessation with
maxillary positioning and nasal profile [63]; however, there final planned occlusion in mind and due to the availability
is no general consensus among surgeons. of custom-made calibrated titanium plates to reduce
relapse, though in SFA, mandibular movements are per-
formed with a horizontal overcorrection of 2 mm to adjust
occlusion to the desired position post-operatively [66].

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Necessity for Surgical Splints microtrauma present during the activation phase of dis-
traction stimulates osteoblast proliferation, bone extracel-
When osteotomy cuts are placed in orthognathic surgery, it lular matrix (ECM) synthesis and induces growth factors
is imperative to use splints, which serve as an intra-oper- [73].
ative guide to establish a pre-surgically planned occlusion. In orthognathic osteotomy sites, the healing is produced
After facebow transfers and mock surgeries, guiding splints by endochondral processes, similar to fracture healing. The
are fabricated for accurate intra-operative bone reposi- position and condition of the osteotomized bone segments
tioning [35, 67]. CAD/CAM splints are used these days, for are vital during repair. The cartilage matrix plays a vital
better accuracy and precision [35]. role in the regulation of products that determine the mat-
Surgical splints are not essential in distraction cases, as uration or apoptosis of chondrocytes and act as a scaffold
it only involves the mobilization of segments, followed by for osteoblast progenitors. The vascular endothelial growth
fixation of the devices. factor that is produced by hypertrophic chondrocytes has a
However, in both the techniques, a surgical guide for fundamental role in the growth and differentiation of
placement of osteotomy cuts/implant fixation and for endochondral ossification [74].
positioning of distractors can be used for surgical accuracy
[68]. Post-surgical Imaging

Role for Transfusion Distraction osteogenesis mandates, regular monitoring of

the progress of the distraction regenerate consolidation,
Distraction procedures are less invasive with a lower direction and dimension of movement, through serial
necessity for post-operative blood transfusion [9, 64], due radiographs. However, factors like radiation exposure and
to minimal manipulation of hard and soft tissues. Bimax- increased cost have led to the usage of ultrasonograms for
illary orthognathic procedures have an increased propen- repetitive evaluation, to determine the degree of bone
sity for post-operative blood transfusions [69] and authors formation [75].
report that, isolated maxillary orthognathic procedures Orthognathic procedures require post-operative radio-
have a higher rate of requirement for blood transfusions graphs to assess the degree of movement and fixation and
[70]. will require further investigation should a complication
However, difference in the techniques for Lefort arise.
osteotomies and additional usage of tranexamic acid has
shown to be very effective in controlling blood loss and Assessment of Post-operative Changes
thereby preventing the need for transfusion [71, 72].
Occlusion
Duration of Surgery
Distraction osteogenesis has a tendency to cause mild to
Incision to closure time for a distraction procedure for severe occlusal discrepancies as the movements are plan-
maxilla or mandible is lower than a similar procedure ned at basal bone level. In children, the changes in the
performed as an orthognathic surgery [9, 64]. The obvious dental occlusion after completion of distraction may be
reasons are that distraction cases don’t require intra-oper- compensated by the appropriate eruption pattern of the
ative positioning in planned occlusion; there is reduced permanent dentition. Posterior open bites and anterior
mobilization of segments, decreased blood loss and better cross-bite are the most common occlusal changes [58].
visibility of the operating field. The duration of the surgery This occurs rapidly, due to the active vertical growth of the
was found to decrease with increasing expertise to the maxilla after it is released from the constriction effect of
procedure [28]. the hypoplastic mandible. In adults undergoing mandibular
distraction, there will be severe alteration of dental occlu-
sion, which will require prolonged orthodontic treatment or
Post-operative Issues secondary orthognathic surgery [9, 57, 58].
Orthognathic surgery relies on planning and pre-
Biomechanics of Bone Healing dictability. The patient undergoes presurgical orthodontics
and the intra-operative final position is determined by the
Histologically, the healing process in sites of distraction splint. After the surgical procedure, the patient is referred
osteogenesis differs from osteotomy in two basic aspects. to the orthodontist to correct the expected post-operative
There is an advantage of having a controlled microtrauma changes in occlusion [27, 67]. Unexpected intra-operative
and an intramembranous ossification. The controlled complications like bad splits, condylar sag or post-

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operative complications like plate fracture could lead to thereby producing excellent aesthetic and functional results
occlusal discrepancies. [9, 14, 58]. Distraction histogenesis occurs due to the
incremental traction of bone, which manipulates the soft
Condylar Position tissue envelope around it to stretch, expand and regenerate
during the process [49, 84].
Long-term studies in orthognathic surgery involving large In orthognathic surgery, as the facial bones are advanced
forward and upward rotations of the maxillomandibular in an acute fashion and fixed in its new planned position,
complex have produced a significant decrease in the joint the adjacent soft tissues are stretched and they tend to
space leading to greater degrees of remodelling in the displace the bony segments back to their previous positions
posterior region of the condyle [76]. The bilateral sagittal to a certain degree [77]. Orthognathic surgery changes the
split osteotomy is notorious for producing inadequate functional matrix (Moss functional matrix hypothesis), as
condylar positioning and displacement, which had led to muscular and soft tissue tension are altered following the
condylar resorption and subsequent internal derangement surgical movements in an acute manner. Literature sup-
[57, 67, 76, 77]. ports acute muscle stretching as a major reason for skeletal
Distraction osteogenesis, which is performed for either relapse following orthognathic surgery.
anteroposterior or transverse discrepancies of the mandible,
has lesser incidences of temporomandibular joint compli- Additional Interventions
cations when compared with procedures like BSSO [57] or
with vertical symphyseal step osteotomies [78]. However, In patients with internal submerged distraction devices, an
if the vectors of distraction for bilateral mandibular dis- additional surgery is necessary, to remove the device
traction are not kept parallel, they have a propensity to [29, 37, 57, 58] and to excise the hypertrophic scarred
develop lateral flaring of the proximal fragments [25]. In tissue at the site of activation arm [10, 85]. In a few
children with Pierre Robin sequence who underwent instances, where there are midline deviations and malro-
bilateral mandibular distraction, a significant decrease in tations of the jaws, additional orthognathic procedures will
the superior joint space was detected. These changes were be needed to achieve an optimal final result [86].
consistent with the extent of the bone tissue newly formed Degradable distractors are not popular, as the ability of the
and with the improvements in coordination and appearance biodegradable plates/screws to withstand the muscular
of the children’s facial structures [79]. forces are not equivalent to titanium plates [87]. Currently,
there are no long-term follow-up studies on the use of
Velopharyngeal Changes internal resorbable distractors in the midface [11].
As orthognathic surgery is usually a definitive single-
In patients undergoing maxillary advancement for moder- stage procedure, the necessity for additional surgeries is
ate cleft maxillary hypoplasia of less than 10 mm, dis- rare. In orthognathic surgeries, fixation is only temporary,
traction osteogenesis has no significant advantage over until healing occurs and few authors have advocated the
orthognathic surgery in preventing velopharyngeal incom- removal of these plates after healing [88]. Though there
petence (VPI) or speech disturbances [80–82]. does not appear to be a consensus in agreement for their
In patients with severe cleft maxillary hypoplasia of removal, this is undertaken routinely in some countries
more than 10 mm, performing a Le Fort I osteotomy [89].The usage of biologically inert and resorbable plates
increases VPI in patients with pre-existing borderline VPI for fixation in orthognathic surgery appears to offer certain
[83], but maxillary advancements achieved through dis- clinical advantages over metal plates, by eliminating the
traction osteogenesis have markedly minimal effects on need for a second surgery for their removal [90], that might
velopharyngeal competence [27]. occur due to any untoward post-operative complications.
Distraction offers a distinct advantage due to the ability
to monitor VPI during the activation phase to quantify Patient Compliance
changes and to halt the process if needed.
Patients should be briefed of the need to activate the dis-
Concomitant Histogenesis tractor device two or more times per day for the entire
period of activation [27, 57], while the patient and their
One of the major advantages of distraction osteogenesis is family are to be counselled to overcome the anxiety and
the concurring distraction histogenesis. This phenomenon distress during this period [11, 91]. External halo distrac-
explains the simultaneous expansion of the soft tissues tion devices due to their bulky nature bring great physical
[29], including skeletal muscles, nerves, ligaments, fat, and social discomfort to the patient [11, 29]. Internal
skin and gingiva [10], in concert with the lengthened bone, devices are hence more preferred [29], but the protrusion of

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the activation arm into the oral cavity may be a source of Orthognathic surgeries are single step procedures, and
significant discomfort during speech and food intake [30]. only the adjuvant orthodontic treatment might cause an
Though the satisfaction rate is high after distraction [82], increase in the treatment duration. With advancements in
the pain and the functional impairment during active dis- orthodontics, a return to normal life is much quicker with
traction are a major drawback [92]. Empathetic commu- an orthognathic option like surgery-first approach (SFA).
nication and addressing patient’s queries while assessing
their compliance and willingness should be assessed prior Complications
to procedure, as not every patient is the same and the
surgeon has to decide who is a good fit for distraction. Relapse
Orthognathic surgery, unlike distraction, is almost
entirely an intraoral procedure which is generally well Distraction osteogenesis has lower relapse rates with larger
tolerated with superior patient compliance. The overall advancements [26, 57], as there is decreased force needed
satisfaction rate of patients, after orthognathic surgeries, is to lengthen the bone due to the phenomenon of distraction
very high [93]. Soh et al. did an extensive review and histogenesis [9]. After mandibular distraction for cranio-
reported that patients experienced an improvement in the facial microsomia, there seems to be a continuous loss of
overall quality of life after orthognathic surgery [94]. the relative height of the ramus with a return towards the
original ratio, as the patient grows [98]. Though significant
Follow-Up Visits skeletal relapse was noted, it did not worsen the treatment
results [99] and this relapse sometimes might be attributed
Constant post-operative follow-up visits are mandatory [9] to the muscular forces acting against the direction of the
following distraction procedures, to check for regularity in distraction.
activation, and also to note the occurrence of complica- In orthognathic surgeries, advancements of more than
tions, if any. This is a particular disadvantage in the Indian 10 mm in any direction are considered to be with an ele-
scenario, as the patient might be coming from a distant vated risk of relapse [20, 21], while few studies even report
place and this might interrupt the regular visits, leading to relapse after advancements of more than 6 mm [100].
complications. In distraction osteogenesis patients, dis- In patients with cleft maxillary hypoplasia, considerable
charge is delayed due to post-operative device activation, relapse occurred after orthognathic surgeries [101, 102],
need for close assessment and vector check, assessment of the causation of which is thought to be the fibrosis of
quantum of movement and prevention of immediate post- structures around the hypoplastic maxilla, while after dis-
operative complications. traction, the relapse rate is significantly minimal [30].
Numerous visits are not necessary after an orthognathic
surgical procedure [28]. The patients need to have one to Post-operative Infection
two post-operative follow-up visits with the surgeon, after
which they are handled by the orthodontist, lest any com- The distraction rods that penetrate the oral mucosa are
plication arise. portals of entry for infection [13, 37]. Chronic infections
have been reported with mandibular distraction cases [15].
Duration of Treatment In patients with internal distraction devices, maintenance
of oral hygiene is an important factor to prevent the
Distraction osteogenesis entails a prolonged treatment occurrence of infections [30]. There is a tendency for
time, lasting at least 3 months [4, 9]. This procedure advocating long-term antibiotics in patients undergoing
involves a consolidation period, which lasts for about distraction through extraoral devices, as there is an expo-
8–12 weeks depending upon the quantum of distraction, sure to the external environment.
hence is one of the major disadvantages. Onger et al. The infection rates in orthognathic surgery patients are
reviewed that the acceleration of regeneration by stimula- very minimal or even nil, if proper antibiotic regimen is
tion of callus during the consolidation period would followed [103]. Recent trials suggest that even post-oper-
shorten the time for treatment [95]. Low-intensity ultra- ative antibiotics are unnecessary after orthognathic surgery,
sound, intermittent parathyroid hormone, calcitonin, zole- if a single dose of perioperative antibiotic prophylaxis had
dronic acid, bone morphogenetic proteins, transforming been administered [104]. Maintenance of oral hygiene and
growth factor, vascular endothelial growth factor, recom- preventing food from accumulating along suture lines are
binant growth factor, cytokines, extracorporeal shock some ways to decrease incidence of post-operative
waves have been used to improve the bone healing and infection.
shorten the consolidation period [96, 97].

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Outcome of Surgical Correction for Facial Symmetry Neurological Deficits

Symmetrical results are not guaranteed in all cases of The larger incidences of persistent long-term inferior
distraction especially bilateral where device failure or alveolar nerve (IAN) disturbances have been reported fol-
premature consolidations may cause asymmetrical move- lowing bilateral sagittal split osteotomy (BSSO) [67, 107].
ments, contrary to what was planned. [18]. Mandibular distraction has lower incidences of persis-
This complication is very unlikely to happen with tent sensory nerve disturbances when compared to
orthognathic surgeries, as bilateral symmetrical movements orthognathic surgery, between 6 and 10 mm of distraction,
are achieved through definitive pre-operative planning and as noted in a review by Cheung [28]. Reasons attributed are
appropriate splint usage [35, 67]. There can be post-oper- the gradual stretching of IAN during distraction, allowing
ative complications like mobility at the osteotomy site and better nerve adaptation [108] and secondly the simpler split
condylar sag, which might produce occlusal discrepancies. of the bone segments (green stick type), with less traumatic
manipulation of IAN intra-operatively [57].
Extra Oral Scarring However, there aren’t many studies to assess nerve
injuries in distraction osteogenesis as there are in orthog-
External distraction devices anchored by transcutaneous nathic surgery. Risk factors for nerve injury are the quan-
pins are used to transport and stabilize the skeletal frag- tum of movement and the rate of distraction, where one
ments [105]. Though there are numerous advantages like millimetre a day in fractions is advised for optimal nerve
less infection rate, easy adjustment of vector and easy histogenesis.
removal, these pins are prone to cause scarring of the skin
[9], which can be minimized if no puckering of skin is Complications in Specific Craniofacial Procedures
produced in between the pins. To circumvent this, internal
distractors are used as there are no skin incisions and they Frequent and severe complications like cerebrospinal fluid
cause no risk to the branches of the facial nerve [105], but leakage, meningitis, subgaleal haematoma, transection of
there are instances, wherein they too have caused hyper- the infraorbital nerve, strabismus and ptosis have a higher
trophic scarring near the activation arm [10, 85]. incidence in patients undergoing LeFort III osteotomy than
Orthognathic surgery has no extra oral scarring as the those undergoing LeFort III distraction [41, 109, 110].
approaches are always made transorally [24], barring a few In the hands of an experienced surgeon, LeFort III dis-
procedures like extraoral ramus osteotomies and Lefort III traction offers minor or no post-operative complications
osteotomies [97, 106].

Table 1 Summary of parameters—DO versus OGS

Parameters Distraction osteogenesis Orthognathic surgery

Paediatric patients 4
Adult patients 4 4
Bone movement of less than 8 mm (maxillary complex) 4 4 (preferred)
Bone movement of 8–10 mm (maxillary complex) 4 4
Bone movement of more than 10 mm (midface/mandible) 4 (preferred) 4
Impaction, retraction, compression of bone 4
Precise 3D movements 4 4 (preferred)
Simultaneous movements of the midface complex (two–three procedures) 4 4 (preferred)
Existing VPI with movement of more than 10 mm 4 (preferred) 4
Calvarial deformity corrections 4 4
Multiple segmentations (movements of 2–3 subunits) 4
Transverse discrepancies 4 (preferred) 4
Segmental defects 4
Irradiated cases 4
Poor bone quality 4
Condylar hypertrophy/hyperplasia 4
Neocondyle rehabilitation 4 (preferred) 4
Symmetrical results 4 4 (preferred)

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 J. Maxillofac. Oral Surg.

[111]. Complications related to mandibular procedures Both the surgical techniques still coexist and thrive all over
have been dealt in detail all along this review. the world; except for a few overlapping indications, the
surgeon still holds the discretion to make the obvious
choice.
Authors’ Conclusions

This review delineates the similarities and differences

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