Craniofacial distraction osteogenesis: A review of 3278 cases

The nascent field of craniofacial distraction osteogenesis has not yet been subjected to a rigorous evaluation of techniques and outcomes. Consequentl y, many of the standard approaches to distraction have been borrowed from t he experience with long bones in orthopedic surgery. The ideal "latency per iod" of neutral fixation, rate and rhythm of distraction, and consolidation period have not yet been determined for the human facial skeleton. In addi tion, because the individual craniofacial surgeon's experience with distrac tion has generally been small, outcomes and meaningful complication rates h ave not vet been published. In this study, a four-page questionnaire was sent to 2476 craniofacial and oral/maxillofacial surgeons throughout the world, asking about their experi ences with distraction osteogenesis. Information about the types of cases, indications for surgery, surgical techniques, postoperative management, out comes, and complications were tabulated. Of 274 respondents (response rate, 11.4 percent), 148 indicated that they used distraction in their surgical practice. One hundred forty-five completed surveys were entered into a data base that provided information about 3278 craniofacial distraction cases. S tatistical analyses were performed comparing the rates of premature consoli dation, fibrous nonunion, and nerve injury, on the basis of the use of a la tency period and different rates and rhythms of distraction. In addition, t he rates of all complications were determined and compared on the basis of the number of distraction cases performed per surgeon. The results of the study clearly show a wide variation in the surgical prac tice of craniofacial distraction osteogenesis. Although the cumulative comp lication rate was found to be 35.6 percent, there is a Pronounced learning curve, with far fewer complications occurring among more experienced surgeo ns (p < 0.001). The presence of inferior alveolar nerve injury as a result of mandibular distraction was much lower for respondents whose distraction regimens consisted of no more than 1 mm of distraction per day (19.5 percen t versus 2.4 percent; p < 0.001). No evidence was found to support the use of a latency period or to divide the daily distraction regimen into more th an one session per day. Conclusions could not be drawn front this study reg arding the length of the consolidation period. Overall, the surgeon-reporte d outcomes are comparable with those published for other craniofacial proce dures, despite the higher incidence of complications. Although conclusions made on the basis of a subjective questionnaire need t o be interpreted cautiously, this study has strength in the large numbers o f cases reviewed. Because of the anonymity of responses, it has been assume d that surgeons who responded to the survey reported accurate numbers of co mplications and successful outcomes. Finally, additional clinical and anima l Studies that will be of benefit in advancing the field of craniofacial di straction osteogenesis are outlined.