BONE TRANSPORT

DISTRACTION OSTEOGENESIS

By:
Alice Wenas

Supervisor:
Asri Arumsari, drg SpBM
INTRODUCTION

Bone transport is a distraction osteogenesis technique,

which was first introduced by Ilizarov for treating long
bone defects that resulted from oncologic resection,
trauma, or congenital deformities (Annino et al., 1994;
Ilizarov, 1988).

This method involves the gradual movement of a free

segment of bone (transport segment or transport disk)
across the osseous
 INTRODUCTION

Treatment of subtotal tibial defect using Ilizarov's bone transport technique.

The transport disk is cut from the proximal segment (left), gradually
distracted through the defect (center), and compressed to the distal segment
(right). Note that distraction regenerate is formed between the proximal and
transport segments.
 INTRODUCTION

According to Ilizarov, they can be divided

into three groups based on the number of
distraction/compression sites. The groups
are monofocal, bifocal, and trifocal.
 INTRODUCTION

 Monofocal osteosynthesis is a distraction

technique in which distraction osteogenesis
occurs during the gradual distraction of bone
segments following an initial period of
compression.
 INTRODUCTION

Bifocal osteosynthesis consists of gradual movement

of a vascularized bony segment or "transport disk"
previously separated from the residual bone segment
adjacent to the defect. New bone is formed during
movement of the transport disk in the distraction site
with simultaneous closing of the bony defect;
compression osteosynthesis then occurs at the
docking site.
 INTRODUCTION

Finally, in cases with large bone defects, two transport

disks can be formed and simultaneously moved toward
each other until touching. This distraction technique,
termed trifocal osteosynthesis, is characterized by
two distraction regenerates formed by simultaneous
distraction, which is followed by subsequent
compression at the docking site.
Biologic foundation

Biologically, bone transport techniques are

based on two separate processes:
- Distraction osteogenesis
- Transformational osteogenesis
 Biologic foundation

Distraction osteogenesis
is a biologic process of
new bone formation
between the surface of
bone segment that are
gradually separate by
incremental traction
 Biologic foundation

Transformational
osteogenesis is a
mechanical induced
biologic process of
pathologic bony tissue
transformation into
normal bone. The
mechanical induction
could be compression or
distraction
 Biologic foundation

Principles of transport distraction osteogenesis technique

Clinical application

In 1990, Constantino and co-workers demonstrated the feasibility of

bone transport techniques for segmental mandibular regeneration using
a canine model
 Clinical application

 The advantage of using bone

transport for reconstruction of
mandibular defect is that mandible
is utilized as the template for
contruction of the neomandible,
which has the same size and
shape as the original mandible.
Additionally, all local soft tissue
(gingiva, buccal and lingual
sulcus) are recreated, an
advantage over conventional bone
grafting technique
 Clinical application

The first report of the

clinical application of
bone transport was
presented in 1995 by
Constantino to restore the
continuity of a mandibular
defect formed as a result
of cancer resection
Distraction rate 0,5 mm twice a day after
following radiation 7 days latency period, followed by 8 weeks
therapy of consolidation
 Clinical application

 Fedotov used an extraoral

semicircular apparatus for
bone transport
 Patient with mandibular defect
ranging from 3.5-4.0 cm used
monofocal distraction
osteogenesis
 Bone defect 4.0 – 5.5 cm
indication for bifocal
mandibular bone transport
 Trifocal DO was used for larger
mandibular defects
 Clinical application

 First IO device for

mandibular bone
transport was developed
in 1987 by Wolfson, but
this distractor never
applied clinically
 More recently, IO device
were developed for
correction of neocondyles
and cleft palates
 Clinical application
C.

A.

Patient with cleft lip and palate with a missing premaxillary segment. A. Preop photograph B.
Diagram demostrating transportation of a portion of residual premakxillary segment anteriorly C.
A modified palatal expansion device
 Clinical application

Patient with a submucous cleft and

velopharyngeal insufficiency
undergoing transport distraction to
move a portion of the hard palate
posteriorly
 Clinical application

 During the process of bone

transport, the leading edge of the
transport disk becomes enveloped
with fibrocatilaginous cap

 If the fibrocartilaginous cap is not

removed, a pseudoarticulation
develops →can be utilized to
create a neocondyle

 Benefit in cases of TMJ ankylosis,

degenerative joint disease, total
joint replacement and dentofacial
deformities resulting from
idiopathic condylar resorption
 Clinical application
Enhancement of Regenerate Bone Formation

Bone segment modification techniques

for increasing the diameter and
bone surface of the bone ends

Non invasive low-intensity pulsed

ultrasound system for acceleration
for fracture healing and formation
of distraction regenerate
PROTOCOLER
 The steps in basic technique are:
 Surgical/osteotomy phase
 Latency phase
 Distraction phase
 Consolidation phase
 Remodeling
 PROTOCOLER

 Surgical phase
 Performanceof an osteotomy or corticotomy
and placement of an expandable device
connected across the bony segment
 Latency phase
 A periodof time for initiation of the healing
process (5-7 days)
 PROTOCOLER

 Distraction phase
 Activationof the device to create tension
across the surgical site
 1 mm per day, twice a day
 Consolidation phase
 Maintenance of the distraction gap where new
bone was formed to allow complete
mineralization of the regenerate bone, leaving
device in place without further activation
 6-8 weeks
Limitation and complication

Although application of local bone transportation

technique have undergone extensive development over
the past 45 years, there are also a limitation:

 Development of hypotropic forms of distraction regenerate,

which usually occurs when bone transport is performed in
pathologic bone or in bone with compromised blood supply
 Unusually long periods required for transformational
osteogenesis at the docking site
 Inadequate length of the residual host bone segment, which
prevent the creation of a sufficient transport segment
 Limitation and complication

Complication encountered during

craniofacial distraction osteogenesis can
be divided into three groups:
 Intraoperatif
 Intradistraction
 Postdistraction
 Limitation and complication

Intraoperative complication similar to

orthognatic surgical technique:
- bleeding problem
- neurosensory deficits
- less than optimum bone split
- device associated complication :
placement/orientation of the device and
the fixation pin and completeness of
the osteotomy
 Limitation and complication

Intradistraction complication:
 Pin infection
 Pin loosening
 Device loosening and dislodgment
 Device failure
 Pin tract formation subsequent scarring
 Inappropriate distraction vector
 Premature consolidation
 Dentigerous cyst formation
 Coronoid process interference
 Fibrous pseudoarthrosis
 Parestesia and trismus
 Limitation and complication

Post distraction complication:

 Malocclusion (openbite)
 Blunting of the gonial angle
 Early relapse
 Failure to release a preexisting joint ankylosis
 Poor growth after distraction
CONCLUSION
 Bone transport is a relatively new distraction
osteogenesis technique that offers many
advantages over conventional methods for
treatment of congenital and acquired bone
defect
 Based on the biologic principles of both
distraction ostegenesis and transformational
osteogenesis, local transportation of the
intercalary segment across the defect results in
formation of distraction regenerate bone
 CONCLUSION

 Subsequent compression at the docking

site provides an environment that
stimulates fusion of the transport and
target bone segment followed by osseous
remodeling
THANK YOU