Article/technical note 1

A new orthodontic-surgical approach to mandibular retrogna- 2

thia 3

Francisco Vale1*, Joana Queiroga1, Flávia Pereira1, Madalena Ribeiro1, Filipa Marques1, Raquel Travassos1, Catarina 4
Nunes1, Anabela Baptista Paula1-5, Inês Francisco1 5

1 University of Coimbra, Institute of Orthodontics, Faculty of Medicine, Coimbra, Portugal; fvale@fmed.uc.pt 6

(F.V.); joana1923@gmail.com (J.Q.); fppereira_@hotmail.com (F.P.); madalenaprata@hotmail.com (M.P.); 7
filipa.p.s.marques@gmail.com (F.M.); raqueltravassos.91@gmail.com (R.T.); mcal9497@hotmail.com (C.N.); 8
anabelabppaula@sapo.pt (A.B.P.); ines70.francisco@gmail.com (I.F.) 9
2 University of Coimbra, Institute of Integrated Clinical Practice, Faculty of Medicine, Coimbra, Portugal; .); 10
3 University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), area of Environment 11
Genetics and Oncobiology (CIMAGO), Faculty of Medicine, Coimbra, Portugal 12
4 University of Coimbra, Centre for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal 13
5 Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal 14
* Correspondence: Francisco Vale, Area de Medicina Dentária — Av. Bissaya Barreto, Bloco de Celas, 3000- 15
075 Coimbra, Portugal. Email: fvale@fmed.uc.pt 16

Abstract: (1) Background: Mandibular deficiency is one of the most common growth disorders of 17
the facial skeleton. Recently, distraction osteogenesis has been suggested as the treatment of choice 18
in order to overcome the limitations of conventional orthognathic surgery.(2) Methods: A new 19
custom-manufactured dental-anchored distractor was built, which was anchored in the 1st molar 20
and lower canine. It consists of a stainless-steel disjunction screw, adapted, and welded to the 21
orthodontic bands through two 1.2 mm diameter connector bars, with universal silver-based and 22
cadmium-free solder.; (3) Results: The distractor described can be a useful tool to correct mandibular 23
retrognathia and is better tolerated by patients, especially in severe cases.; (4) Conclusions: The 24
dental-anchored distractor increases the anterior mandibular bone segment without affecting the 25
Citation: Lastname, F.; Lastname, F.;
Lastname, F. Title. Bioengineering
gonial angle or transverse angulation of the segments, and avoids posterior mandibular rotation, 26
2021, 8, x. overcoming the limitations of conventional surgical treatment. 27
https://doi.org/10.3390/xxxxx
Keywords: Distraction osteogenesis; Mandible; Orthognathic Surgery 28
Academic Editor: Firstname 29
Lastname

Received: date 1. Introduction 30

Accepted: date
Mandibular hypoplasia is the most common growth disorder of the facial skeleton 31
Published: date
in Western Europe with a prevalence ranging from 41% to 56%, this condition is 32

Publisher’s Note: MDPI stays

commonly associated with an Angle class II occlusion, convex profile, and a mandibular 33

neutral with regard to jurisdictional

deficiency[1,2]. 34
claims in published maps and Mandibular deficiency has a variety of causes, ranging from embryogenesis to 35
institutional affiliations. postnatal causes. This condition and can occur isolated or in association with congenital 36
malformation syndromes and depending on its severity it can require orthodontic- 37
surgical-orthognathic treatment[2]. 38
Several studies have reported that certain malocclusions, including skeletal Class II, 39
Copyright: © 2021 by the authors. are associated with decreased masticatory efficiency, abnormal speech, pain, and 40
Submitted for possible open access decreased social interaction[3]. Bernabé et al. [4] conducted a study in Brazilian 41
publication under the terms and
adolescents describing the impacts of oral health on the quality of life based on 42
conditions of the Creative Commons
malocclusion. The authors verified that those with Class II malocclusion reported a higher 43
Attribution (CC BY) license
direct impact on quality of life when compared with normal and Class I malocclusion. 44
(https://creativecommons.org/license
The surgical and orthodontic treatment of mandibular deficiency progressed 45
s/by/4.0/).
significantly in the second half of the twentieth century with the introduction of new 46

Bioengineering 2021, 8, x. https://doi.org/10.3390/xxxxx www.mdpi.com/journal/bioengineering

Bioengineering 2021, 8, x FOR PEER REVIEW 2 of 7

techniques and materials. These procedures have a primary goal of restoring dental 47
occlusion, masticatory function, respiratory function and harmony in patients with class 48
II skeletal malformations [5,6]. 49
For the correction of this deformity, the most frequent treatment encompasses a 50
conventional orthodontic-surgical-orthognathic protocol which is divided into four 51
stages. The first one is the presurgical orthodontic phase, this step is crucial as it is set to 52
eliminate tooth compensation, harmonize the dental arches and place the teeth in a stable 53
position regarding the bone bases. This is followed by the surgical phase comprised of a 54
bilateral bisagittal osteotomy (BSSO) which is the most commonly performed thechnique 55
although it has several different variations. The post surgical stage is a combination of 56
recovery and orthodontic refinements and the final stage is an optional surgical 57
intervention to remove the osteosynthesis plates. 58
The surgery itself is performed under general anesthesia and usually requires 4 to 6 59
weeks of rigid or non-rigid maxillomandibular fixation. As for the post-surgical 60
orthodontic phase takes around 6 months on average and during this period bone tissue 61
is consolidated and the dental occlusion is adjusted in an attempt to prevent or 62
camouflage small skeletal relapse. 63
Although this protocol is very commonplace, it is not exempt of risk or handicaps. 64
This intervention will generally increase the overall treatment time as mandibular 65
premolar extractions are usually required in order to allow for dental compensation 66
correction, the surgery is only recommended to be performed on adult patients (after 67
completion of skeletal growth), it also presents itself with a high relapse rate and it is an 68
expensive and temporarily incapacitating procedure [7,8]. To overcome these limitations, 69
conventional surgical treatment is gradually being replaced by other techniques, such as 70
mandibular distraction osteogenesis (DO) [9]. 71
The American Association of Oral and Maxillofacial Surgeons and other researchers 72
reported several situations for which distraction osteogenesis should the chosen 73
procedure for mandibular elongation: Hemifacial Microsomia - unilateral distraction 74
of the ascending ramus, mandibular angle, or posterior part of the mandibular body; 75
mandibular body segmental defects due to trauma or tumor entity; class II syndrome 76
caused by mandibular position (retrognathia) or dimension insufficiency (brachygnathia); 77
micrognathia caused by trauma and temporomandibular joint ankylosis; vertical alveolar 78
distraction for occlusal plane correction and deficiencies in the position and dimension of 79
the alveolar ridges for dental implant rehabilitation and also for mandibular elongation 80
in obstructive apnea syndrome [10–16]. 81
Several authors have attempted to compare BSSO and DO procedures and the 82
reported results were contradictory. Al-Moraissi et al.[1] conducted a systematic review 83
with a meta-analysis to determine whether there were differences in skeletal stability and 84
neurosensory disturbance of the inferior alveolar nerve between BSSO and DO concerning 85
mandibular advancement surgery. A statistically significant difference in neurosensory 86
disturbance of inferior alveolar ramus function was found between the BSSO and DO (P 87
=.004), and the authors' findings showed that distraction osteogenesis significantly 88
reduced the incidence of neurosensory disturbance of the inferior alveolar ramus after 89
lengthening of the retrognathic mandible when compared to the BBSO. However, these 90
findings could not be confirmed in other studies. Akkerman et al.[17] conducted a review 91
comparing both techniques for mandibular advancement because it was assumed that DO 92
would result in better stability and lower neurosensory disturbances of the inferior 93
alveolar ramus. Nonetheless, based on the included prospective studies, the authors 94
concluded that BSSO is not only superior in terms of stability and neurosensory 95
disturbances in the inferior alveolar nerve but it also seems to result in less pain and lower 96
total costs. Some systematic reviews that compared the effectiveness of distraction 97
osteogenesis versus orthognathic surgery in cleft patients verified that both methods can 98
produce significant hard and soft tissue improvements but the relapse rate is lower in the 99
distraction osteogenesis group five years post-surgery [13,18] 100
Bioengineering 2021, 8, x FOR PEER REVIEW 3 of 7

The available experimental and clinical studies are mostly about external distractors. 101
Despite their biomechanical advantages, external distractors have more side effects from 102
the patients' point of view as it's more disabling, psychosocial problems can arise due to 103
the distractor's visibility and volume and there is also perceptible scarring on the face. The 104
disadvantages don't end there as there is instability in distractor fixation, a risk of dental 105
and/or nerve injury (placement-osteotomy-removal), edema is generally present and the 106
wounds are propitious to localized infections.[19–23]. 107
All of these limitations often resulted in the rejection of the external distractors, 108
requiring the development of alternative mechanics: the intraoral distractors that were 109
nothing more than miniaturizations of existing external devices and/or adaptations of 110
orthodontic devices for maxillary disjunction. 111
McCarthy et al. [24] in 1992 were the first to use internal distractors and they were 112
able to eliminate the problems of scarring sequelae and the visibility of external 113
distractors, but the risks and limitations of fixation remained. 114
Regarding dental-anchored distractors, Guerrero used an intraoral distractor to 115
correct mandibular deformities for the first time in 1990, using a modified Hyrax-type 116
appliance cemented to the first premolars and lower molars [20]. Razdolky et al.[24] 117
pointed out several benefits of these devices over traditional distractors, namely fixation 118
as it was performed directly on the teeth and no surgical intervention was required for 119
placement or removal, making the internal dental-anchored distractor less invasive [23]. 120
The The surgical act can be reduced to only corticotomies or osteotomies, allowing for an 121
outpatient procedure without the need for an extensive stay in the hospital or general 122
anesthesia. When compared to traditional distractors the device placement is easier 123
allowing for the distraction to occur parallel to the chosen vector or occlusal plane, 124
avoiding posterior mandibular rotation, and making orthodontic treatment easier [25]. 125
The aim of this study is to describe a new custom-manufactured dental-anchored 126
distractor anchored in the 1st molar and lower canine to perform the sagittal distraction 127
of the mandible as parallel to the occlusal plane as possible. 128

2. Materials and Methods 129

A new custom-manufactured dental-anchored distractor design was elaborated, 130
anchored in the 1st molar and lower canine. It consists of a stainless-steel disjunction 131
screw, adapted, and welded to the orthodontic bands through two 1.2 mm diameter 132
connector bars, with universal silver-based and cadmium-free solder, 0.1 mm in diameter 133
(figure 1). The mechanism of the screw is the rotation-pressure type, allowing the 134
dismultiplication of the effort for the elongation, with a maximum expansion of 12 mm. 135
The rotational movement of 360º around its axis produces a translational movement along 136
this axis (sagittal elongation) of 0.8 mm. A single screw activation allows only a rotation 137
of 90º (1/4 turn), producing a 0.2 mm elongation, and features a brake system that prevents 138
the accidental return of the activation. 139

140
Figure 1. Photography of the custom-manufactured dental-anchored distractor. 141

Surgically, the corticotomy is performed between the lower premolars, with slight 142
deviation to preserve the continuity of the inferior alveolar neurovascular bundle. 143
Bioengineering 2021, 8, x FOR PEER REVIEW 4 of 7

3. Results 144
After 7 days of latency, the process of increasing the mandibular length initiates, with 145
a distraction rate of 1 mm/day (0.5mm every 12 hours). The distractors anchored to the 146
teeth and parallel to the occlusal plane allow a significant increase of the anterior bone 147
segment, without any side effects at the gonial angle or alteration of the transverse angu- 148
lation of the bone segments (figure 2). Therefore, the tooth-borne distractor produces a 149
correct lengthening direction which facilitates the creation of the desirable stress force 150
necessary for the osteogenesis process, instead of an undesirable compression force. 151
During the active period of distraction, a mechanical force is applied to the soft callus, 152
preventing fracture healing, and creating a unique and highly dynamic microenviron- 153
ment. The soft tissues, such as the epidermis, dermis, blood vessels, tendons, muscles, and 154
nerves, gradually follow bone growth as a result of the tension forces applied to the bone 155
segments (figure 3) [24,26,27]. 156

157

158

159

160

161

162

Figure 2. Intra oral mandibular photography before and after the distraction osteogenesis with the dento-anchored dis- 163
tractor. 164

165
Figure 3. Ortopantomography before and after the distraction osteogenesis with the dento-anchored distractor. 166

4. Discussion 167
Because of the enormous potential of distraction osteogenesis in the treatment of den- 168
tofacial deformities, the interest and use of this technique in orthodontics and maxillofa- 169
cial surgery has grown significantly in recent years. Its late appearance in orthopedics can 170
be explained in part by the anatomical characteristics of the craniofacial region, which 171
make distraction devices difficult to apply. Indeed, the morphology of the bones of the 172
facial mass is more complex, the scars are less tolerable than in other parts of the body, 173
and conventional maxillofacial surgery techniques allowed for the resolution of a large 174
portion of the severe facial deformations. 175
The main interest of distraction osteogenesis is the regenerative nature. The gradual 176
and controlled elongation that allows tissue regeneration and repair, that occurs not only 177
in the bone skeleton, but also in soft tissue associated with it, including muscles, subcuta- 178
neous cellular tissue, and skin. This feature is particularly important in the treatment of 179
dento-skeletal deformities that require mandibular advancement, and in determining the 180
Bioengineering 2021, 8, x FOR PEER REVIEW 5 of 7

choice of distraction osteogenesis technique over conventional orthognathic surgery, as 181

well as substantially reducing the risk of relapse caused by strong soft tissue ten- 182
sions.[24,28–30]. 183
Dental-anchored distractors are only used intraorally and are bonded to the teeth. 184
Despite having significant advantages, such as little psychosocial impact on the patient, 185
reduced dimensions, no risk of infection, less invasive and no need for surgical interven- 186
tion in placement and removal, less morbidity, and greater stability in the anchorage, they 187
have been poorly studied for use in sagittal dentoskeletal deformities, being primarily 188
used to treat transverse jaw deformities [20,31,32]. 189
The inclusion of a connector bar in the anterior segment that connects both mandib- 190
ular right and left sides, the design of our dento-anchored distractor, allowed significant 191
increase of the anterior bone segment without affecting the transverse angulation of the 192
bone segments. 193

5. Conclusions 194
The use of a dental-anchored distractor allows its placement and removal without 195
demanding surgery. The osteogenic distraction using a dental-anchored distractor is effi- 196
cient in the sagittal lengthening of the jaw. Therefore, this procedure represents a new 197
orthodontic surgical treatment approach alternative to the mandibular bilateral sagittal 198
split osteotomy and should be considered as a treatment option for mandibular hypo- 199
plasia. 200

Funding: This research received no external funding. 201

Institutional Review Board Statement: Not Applicable. 202

Informed Consent Statement: Informed consent was obtained from the subject involved in the 203
study. 204

Data Availability Statement: The data presented in this study are available on request from the 205
corresponding author 206

Conflicts of Interest: The authors declare no conflict of interest. 207

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