Sutural Distraction Osteogenesis (SDO)Versus Osteotomy Distraction Osteogenesis(ODO) for Midfacial Advancement: A NewTechnique and Primary Clinical Report

Chunming Liu, MD, DDS,* Min Hou, MD, DDS,* Limin Liang, MD, DDS,* Xuming Huang, DDS,*Tong Zhang, DDS,* Haizhong Zhang, MD, DDS,* Xiao Ma, DDS,* Ruyao Song, MD, DDSy

Beijing, China

A new technique of osteotomy distraction osteo-genesis (ODO) and sutural distraction osteogenesis(SDO) by the use of bone-borne traction hooks ispresented. The technique of osteotomy plus dis-traction osteogenesis is suitable for adult patients.The technique of sutural distraction osteogenesis issuitable for young patients, ages 6 through 12 years.The distraction system consists of a face-bow, ortho-dontic elastics, and bone-borne traction hooks. Thebone-borne traction hooks are made of titanium,with two traction hooks running laterally or down-wardly. When a Le Fort III osteotomy is needed,bone-borne traction hooks are inserted throughthe nostrils into a bone hole drilled at the lateral-inferior pyriform aperture. When no osteotomy isneeded, only the bone-borne traction hooks areplaced. Heavy elastics were used in the techniqueof osteotomy distraction osteogenesis for Le FortIII osteotomy adult patients, whereas light forcesand thus light elastics were used for younger pa-tients. Three adult patients and four children weretreated by osteotomy distraction and sutural dis-traction, respectively. All seven patients with mid-facial hypoplasia established a harmonious facialprofile and normal occlusal relationships. Radio-graphic examination showed balanced advancementof the midfacial skeleton. It is suggested that thetreatment of midfacial hypoplasia in children bythe technique of sutural distraction osteogenesis isto be preferred because of its simplicity and relativenoninvasiveness. Thus, the authors suggest that

midfacial hypoplasia should be treated at a youngerage by this technique, potentially eliminatingthe need for a Le Fort III osteotomy at an older age.

Midfacial hypoplasia is a common de-forfmity in craniofacial surgery. In se-vere cases, complications such asbleeding, instability, and high rates of

relapse may occur after traditional orthognathic ad-vancement. In addition, scar restriction and the in-ability to adequately advance the maxilla may beseen in the patient with a severe cleft deformity.1,2

Distraction osteogenesis provides an easier, safer,and more efficacious method for correction of severemidfacial hypoplasia.

In 1974, Calabrese et al3 reported an experimen-tal study on altering the dimensions of the canine faceby the induction of new bone formation. This prob-ably was the first report about midfacial osteotomydistraction osteogenesis (ODO). This technique wasconfirmed by Rachmiel et al4 in 1993 and soon fol-lowed by clinical applications.5–9 Currently, thereare three kinds of techniques of maxillary and mid-facial osteotomy distraction: (1) internal distractiontechniques,5,7,8 (2) technique of tooth-borne facemaskprotraction,7,9 and (3) technique of tooth-borne rigidexternal distraction.6 In 1995, Staffenberg et al10 re-ported experimental protraction ofmidfacial skeletonwithout osteotomy (ie, the technique of suturaldistraction osteogenesis [SDO]).

Since 1998, seven adult and pediatric patientswith severe midfacial hypoplasia have been treatedat the 301 Hospital, Beijing, China, through ODOand SDO without osteotomy by using bone-bornetraction hooks secured in medium location of themidface skeleton through the nostrils and a facebow.

From the *301 Hospital and Postgraduate Medical Collegeof P.L.A., Beijing, P.R. China; and the yPlastic Surgery Hospital,Peking Union Medical College, Beijing, China.

Address correspondence and reprint requests to Dr. ChunmingLiu, Fu Xing Road No 28, Beijing 100853, Beijing, China; E-mail:liuchm@yahoo.com.

537

PATIENTS AND METHODS

Preoperative Evaluation

P atients with midface hypoplasia were evaluatedwith a comprehensive clinical examination, den-

tal study models, and cephalometric analysis. Ceph-alometric recordswere obtained before surgery, at thecompletion of distraction, and at 6-month intervals.Speech was evaluated before and after treatment bya language pathologist.

The treatment process was explained to patientsand family before surgery, including the osteotomies,if needed, the application of the distraction system,and the time needed for distraction and retention. Itis important that the patient and parents understandthoroughly the treatment protocol.

The clinical data of the seven patients are listedin Table 1.

Distraction System

The distraction system consists of bone-bornedistraction hooks (BBDH), a face bow, and orthodon-tic elastics. The original BBDH was made of a thickstainless steel wire and successfully used in a patientafter a Le Fort III osteotomy.After that, a refined BBDHwas designed. It wasmade of pure titanium, with twotraction hooks coursing laterally (used in cleft pa-tients) or downwardly (used in noncleft patients) witha screw cap at the end of each hook for fixing the hookin location. The two hooks were connected by a trans-verse bar. From the transverse bar, protrude two lon-gitudinal and parallel rods to join the hooks (Fig 1).

Treatment Procedure

There are two techniques for correction of mid-facial hypoplasia that vary according to the patient’sage. These are (1) the technique of ODO and (2) thetechnique of SDO. ODO is suitable for patients olderthan 12 years of age, whereas SDO is reserved for

patients 6 to 12 years of age. The distraction systemis the same in the two patient populations.

Osteotomy Distraction Osteogenesis

Osteotomy and distraction preparation.

A Le Fort III osteotomy was performed in allthree adult patients. A preoperative two-dimensionalcomputed tomography (CT) scan in the coronal planewas obtained to determine the location of the cribri-form plate and to avoid damage to the brain in pa-tients with a low lying cribriform. Exposure of themidface and orbits was obtained through a standardcoronal incision and a transpalpebral incision. At thetemporal region, the superficial layer of the deeptemporal fascia was incised and dissection was doneunder this layer (so that the facial nerve could beprotected) and the soft tissue envelop elevated fromthe lateral orbital rim and zygoma. The dissectionwas carried on to the surface of the nasal bone anddown to its distal point and also over the maxilla.Medially, the dissection was carried medially intothe orbit, behind the medial canthal ligament withoutdetachment of the ligament, down to the medial-inferior orbital wall. The dissection was extended

Fig 1 The new design of bone-borne traction hooks madeof titanium.

Table 1. Clinical Data of the Samples

Number Age (year) Sex Diagnosis Management

1 19 M UCL/P Osteotomy/distraction

2 18 F Noncleft Osteotomy/distraction

3 18 F UCL/P Osteotomy/distraction

4 17 M Noncleft Osteotomy/distraction

5 12 M BCL/P Sutural distraction

6 9 M Noncleft Sutural distraction

7 6 M UCL/P Sutural distraction

8 12 M UCL/P Sutural distraction

UCL/P¼ unilateral cleft lip and palate; BCL/P¼ bilateral cleft lip and palate.

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 4 July 2005

538

in the lateral orbit until the inferior orbital fissurewas clearly seen. The orbital floor was exposedthrough the transpalpebral incision, connecting themedial and lateral subperiosteal dissections. Themidfacial envelop was stretched gently to minimizethe forces restricting the midfacial advancement.

The Le Fort III osteotomy was initiated laterallyas a short and transverse osteotomy at the zygoma-ticofrontal suture. The body of the zygoma was thencut where it meets the arch. A retractor was used toprotect the orbital contents, and the osteotomy wascarried intraorbitally from the zygomaticofrontal su-ture down to the inferior orbital fissure. The osteot-omy was then completed on the opposite side. Afterboth lateral osteotomies were completed, the medialosteotomy was performed. The CTscan was reviewedonce more to determine the location of the cribriformplate. A transverse osteotomy was undertaken at thenasal base and extended posterior to the medial can-thal ligaments and the nasolacrimal groove. Osteot-omy of orbital floor was made with a narrow andsharp osteotome. Attention was paid to avoid dam-age to the infraorbital nerve that runs in the infraor-bital groove: a tiny intact bone segment left at the siteof the nerve did not affect the midface advancement.

An incision was then made inside of the maxil-lary tuberosity, lateral to the palatine major neurovas-cular bundles and foramen. For the osteotomy of thejunction of the maxilla and pterygoid plate, a straightchisel was used, because it is easier than the traditionalmaneuver of dividing the junction from the buccalside using a curved osteotome. The osteotomy thenturned anteriorly, along the posterior alveolar base,to a point about 1 cm from the junction of the maxillaand the pterygoid plate. At this point, the osteotomyextended angled medially to the midline of the pal-ate, under the palatal mucoperiosteum. This maneu-ver might prevent soft-palate advancement that mayaggravate palatopharyngeal incompetence.

The Rowe Kiley forceps were placed intranasallyand intraorally. The midface was then rocked gently;forced down-fracture or excess movement of themidface was unnecessary.

An anterior upper buccal sulcus incision wasmade to expose the rim of the pyriform aperture.A hole was drilled outside of the lateral rim of thepyriform aperture, about 5 mm above the level of na-sal floor, through the lateral nasal wall, with a thickfissure burr. The traction hook was introduced fromthe nostril (Fig 2), and a screwwas secured to the endof hook, thus fixing the hook in place. The same ma-nipulation was done on the opposite side. Attentionwas paid to ensure that the holes were drilled at thesame perpendicular height. In the cleft patients, the

length of the hook used in the cleft side was 3 mmlonger because of the more retrograde maxilla onthe affected side.

The wounds were irrigated with antibiotic-con-taining solution. Lateral canthopexies were done toelevate the lateral aspect of the palpebral aperture.The coronal flap was redraped on the skeleton andclosed in standard two-layer technique. Drains wereplaced under the scalp flap.

Distraction

Three days after Le Fort III osteotomy, the twohooks secured in bone of the pyriform aperture rimwere connected with the transverse bar. The facebow was mounted in place, orthodontic elastics wereapplied, and distraction was begun (Fig 3). Distrac-tion was initiated with heavy elastics, and once thecorrect skeletal position was achieved was retainedby the application of light elastics until consolidationwas complete. In the former, this was done by wear-ing the appliance 24 hours a day, whereas in the latter,night-time use for 12 to 14 hours a day was all thatwas necessary.

Wounds were bandaged for 7 days. Periopera-tive antibiotics were routinely used for 7 days. Allpatients began a soft diet 24 hours after surgery.

Sutural Distraction

Placement of the distraction device.

The sutural distractionwas used for correction inpatients ages 6 through 12 years withmidfacial hypo-plasia. The distraction apparatus is the same as thatof osteotomy distraction. The technique of placementof the traction device is the same as that alreadydescribed. In the noncleft patient, a downward BBDHwas used. One bone hole was drilled on each side

Fig 2 The sketch showed Le Fort III osteotomy and instal-lation of bone-borne traction hooks in bone holes drilled lat-eral to rim of the pyriform aperture, through the nostrils.(A) Front view. (B) Lateral view.

ODO VS SDO FOR MIDFACIAL ADVANCEMENT / Liu et al

539

of the hard palate through the nasal floor. The tractionhook was introduced from the nostril by a soft tubeinto the bone hole. A screw was secured to the end ofhook from the oral side. The same manipulation wasdone on the opposite side. The holes drilled in thehard palate were at the same anterior-posterior level.

One day after surgery, the hooks were connectedwith the transverse bar, and the face bow and elasticswere placed and distraction initiated (Fig 4). Thesame protocol of active distraction followed by reten-tion distraction, during which the distraction devicecould be removed at school time, was used.

The times and forces in both the ODO and SDOpatients are shown in Table 2.

RESULTS

A ll patients had an uneventful recovery, and therewas no surgical morbidity. There was no loosen-

ing of the bone-borne distraction hooks in any patientduring the active and retention phases, and therewere no complications to the nasal cavity and maxil-lary sinus. During the retention phase, all the external

Fig 3 A face bow and orthodontic elastics were used formidfacial osteotomy distraction.

Fig 4 Sutural distraction of the midfacial skeleton.

Table 2. The Times and Forces of Distraction

Number Treatment

Latent

(day)

Distraction

Force (g)

Last

Time (day)

Retaining

Force (g)

Retaining

Time (days)

1 ODO 3 3,800 20 1,000 60

2 ODO 3 3,400 18 800 60

3 ODO 3 3,400 17 1,000 80

4 ODO 3 3,500 16 800 90

5 SDO 1 800 30 200 150

6 SDO 1 800 35 200 190

7 SDO 1 600 40 200 90

8 SDO 1 400 48 200 150

ODO ¼ osteotomy distraction osteogenesis; SDO ¼ sutural distraction osteo-

genesis.

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 4 July 2005

540

devices, including the connecting bar and the facebow, could be removed and remounted easily bythe patient. None of patients and families had diffi-culty following the distraction instructions, and noneof the children who wore the distraction device expe-rienced inconvenience or accidental injury.

All patients achieved satisfactory face contour andnormal occlusal relationship. No open-bite was seen inany patient. The midface advancement in all patientswas balanced in both the upper and lower face. Theretrograde nose, suborbit, zygoma, maxilla, andcross-bitewere all ideally corrected (Figs 5–18). The av-erage advancement was 10 mm in the ODO group and8 mm in the SDO group. No relapse was seen eitherclinically or skeletally at 6months or longer. At least 6months’ follow-up showed no relapse. The group ofchildren treated by the technique of SDO may needmore time to evaluate subsequent growth.

In both techniques of SDO and ODO, the bone-borne traction hooks traverse the anterior-medial cor-ner of the maxillary sinus. No complications of sinusinfection, nasal cavity inflammation, bleeding, or fis-tula were observed in any patient.

DISCUSSION

I n patients born with complete unilateral cleft ofthe lip and palate, the incidence of subsequent

midfacial hypoplasia has been estimated to be 25%to 60%. In the more severely affected children andadults, it may be difficult to advance themaxilla a dis-tance of more than 10 to 12 mm. Even if one managedto do so, the advancedmaxilla usually is unstable andtends to relapse.1,11–13 For these reasons, surgeonsmay compromise, advancing the maxilla and settingback the mandible appropriately, even though the

Fig 5 An 18-year-old girl with midfacial hypoplasia,before treatment.

Fig 6 The same girl gained a harmonious facial profileafter Le Fort III osteotomy distraction.

ODO VS SDO FOR MIDFACIAL ADVANCEMENT / Liu et al

541

mandible is normal in both size and position or evensmall and retrognathic.2

Another disadvantage with traditional orthog-nathic techniques in the correction of maxillary ormidfacial hypoplasia is that the operationmust be de-layed until the age when skeletal maturity has beenreached, leaving the young patient to endure the aes-thetic and functional consequences.

The most appropriate procedure for these pa-tients is debatable. Surgeons commonly prefer theLe Fort I, rather than Le Fort III, osteotomy becausethe former is much easier and safer to perform thanthe latter. However, in severemidfacial hypoplasia, inour experience, the Le Fort I osteotomy may producean unharmonious facial profile, with a protrudedmouth and still retropositioned zygoma, suborbit,and nose.

Since McCarthy first reported the pioneeringwork in 1992,14 the principle of distraction osteogen-esis has been rapidly and extensively used in the cra-niofacial skeleton. The application of distractiontechniques in maxillary and midfacial hypoplasiahas overcome many difficulties associated with tra-ditional orthognathic approaches. (1) The maxillarycomplex can be advanced as much as twice the dis-tance offered by the traditional surgical approaches.(2) It is unnecessary to delay the operation until theages of skeletal maturity; surgical correction can beconducted as early as 5 or 6 years of age, with or with-out Le Fort osteotomy.15 (3) There is no need for estab-lishing normal occlusion during the operation, so oralintubation can be chosen. (4) The existing pharyngealflap needs no special care. (5) With distraction osteo-genesis, the Le Fort III osteotomy becomes easier andsafer than the traditional technique because it is un-necessary to extensively mobilize the segment a large

Fig 7 Occlusion of the adult patient with midfacial hypo-plasia, before treatment.

Fig 8 Corrected occlusion after Le Fort III osteotomy anddistraction.

Fig 9 Cephalometric radiograph of the adult patient withmidfacial hypoplasia, before treatment.

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 4 July 2005

542

distance, and there is no need for bone grafts and fix-ation. The Le Fort III osteotomy allows surgeons tocreate a more harmonious facial profile in certainpatients with severe deformity.

Le Fort III distraction for midface hypoplasia canbe performed with both external and internal devi-ces.5–9,15 The apparatus of external distraction usuallyconsists of two main parts: an external framework,either rigid or moveable, and a dental arch appliance.There are several problems with this kind of tech-nique. First, it requires an intact dental arch. Second,the force exerted on the maxilla is too inferior, farfrom the maximal area of resistance, and may causerotation during advancement. To eliminate this dis-advantage, Polley and Figueroa6 designed externaltraction hooks on the base of intraoral appliance. Theinternal technique may lead to greater injury becauseof the need of a better exposure and distractor place-ment. Positioning of the distractor needs to be muchmore accurate to ensure the bilateral distractors are

fixed at the correct position, direction, and level. In-accurate manipulation may lead to unexpectedmovement of the bone bloc.15,16

In the current technique, bone-borne hooks weredesigned to draw the bone forward, coinciding withthe plane of maximum resistance.17–19 This positionallows the midfacial skeleton to be protracted bal-anced without rotation (Fig 19). The direction of dis-traction can be adjusted straight-forward or inferior-anteriorly. There is no visible scar on the face, and nopotential for dental injury. After the initial distractionphase, the face bow and outer part of the bone-bornedevice can be removed during the day and reinstalledat night by the patient, allowing greater convenienceand flexibility with social and school activities.

With use of the face bow and elastics, no under-correction was seen in our three adult Le Fort III os-teotomypatients. All patients gained normal occlusion.The key point to achieving a satisfactory result lies in

Fig 10 The radiograph showed balanced advancementof the midfacial skeleton after osteotomy distraction. Fig 11 A 12-year-old boy with cleft lip and palate and

midfacial hypoplasia, before treatment.

ODO VS SDO FOR MIDFACIAL ADVANCEMENT / Liu et al

543

the osteotomy. Osteotomy should be complete, andthe midfacial complex should be appropriately mov-eable. The maximum forces used in the patients was3,800 g, which is potentially compromising to the softtissue of the forehead and chin, and measures shouldbe taken to prevent skin breakdown.

Sutural distraction osteogenesis is another kindof technique under the principle of gradual skeletaldistraction. The use of SDO arose from orthodonticsand has a history of more than 100 years.20 However,the term ‘‘sutural distraction osteogenesis’’ was firstproposed by McCarthy in 2000.21 SDO has been usedby orthodontists to advance the retrograde maxillarydental arch and expand the midpalatal suture for cor-rection of a narrow maxillary arch for decays.22–45

There are also some reports dealing with other su-tures.21,46–50 This traditional management of maxil-lary advancement commonly uses a face bow or facemask, an intraoral appliance fixed to the dental arch,

and elastics. It has little influence on the retrogrademaxillary skeleton51 because of the lower positionof the distraction force (Fig 20A). This situation hasbeen changed by the current technique of sutural dis-traction (Fig 20B).

The technique of SDO is the same as the tech-nique of ODO in that both use forces to gradually dis-tract the bone segments bordered upon, inducingnew bone formation at the site of their connection.However, there are four additional aspects worth not-ing: (1) The connection of the bone segments border-ing the site of distraction is natural suture in SDO,whereas in ODO, it is newly formed fibrous callus.(2) With the use of SDO, there is no need for osteot-omy, fixation of bone segments, and a latent phasewaiting for fibrous callus formation. Thus, it is muchsimpler and easier to manipulate and much less in-vasive. (3) The suture is, in nature, the growth zoneof the craniofacial skeleton, and thus possesses

Fig 12 The same boywith a harmonious facial profile aftermidfacial sutural distraction.

Fig 13 A 6-year-old child with cleft lip and palate andmidfacial hypoplasia, before treatment.

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 4 July 2005

544

Fig 14 The same child with a harmonious facial profileafter midfacial sutural distraction.

Fig 15 Occlusion of the child with midfacial hypoplasia,before treatment.

Fig 16 Corrected occlusion after sutural distraction.

Fig 17 Cephalometric radiograph of the child with midfa-cial hypoplasia, before treatment.

ODO VS SDO FOR MIDFACIAL ADVANCEMENT / Liu et al

545

a greater potential of bone regeneration during thedevelopmental ages. (4) SDO is suitable only foryoung patients because of sutural alteration occurswith age.52–56 In children, we install only the bone-borne device and then distract, observing satisfactoryresults, harmonious facial contour, and normal occlu-sion several months later. It is easy to manipulate andless invasive: similar to orthodontic management. Innoncleft patients, the downward hook that traversesthe bone of the nasal floor can be usedwith evenmoreease. Orthodontic protraction in the phase of mixeddenture is a routine practice of orthodontics. Its ap-plication is usually limited by denture condition.It needs a relative intact denture for fixing the intra-oral appliance. It is mainly effective for nonbony orminor-bony hypoplasia, and the management maycause teeth damage. In the current technique, thereis no limitation from the dental condition. It effectivelyexpands the bone, and there is no damage to the teeth.

In the end of his textbook, Distraction of Cranio-facial Skeleton, Dr. McCarthy writes: ‘‘As one looks tothe future, the craniofacial surgeon will obviously beless interventive in the operating room. He will, how-ever, be more involved in the postoperative manipu-lation of the bony regenerate. He will spend moretime in the clinic than in the operating rooms. Bonegraft harvesting will become a matter of surgical his-tory and elaborate fixation system will be displayedin museum exhibits. Blood bank will be necessaryonly for acute trauma cases.’’44a Treatment of midfa-cial hypoplasia of the child by the current techniquesatisfies many of these tenets. Thus, we advocatetreating the midfacial hypoplasia at a young age bythe technique of sutural distraction osteogenesis,eliminating the need for a Le Fort III osteotomy.

Fig 18 The radiograph showed balanced advancementof the midfacial skeleton after sutural distraction.

Fig 19 The bone-borne hooks were designed to draw thebone forward, coinciding with the plane of maximum resis-tance. This position allows the osteotomy midfacial skele-ton to be advanced balanced without rotation.

Fig 20 (A) Traditional orthodontic protraction has little in-fluence on the retrograde maxillary skeleton because of thelower position of the distraction force. (B) This situation hasbeen changed by the current technique of sutural distraction.

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 4 July 2005

546

REFERENCES

1. HochbanW, Gans C, AustermannKH. Long-term results aftermaxillary advancement in patients with cleft. Cleft Palate Cra-niofac J 1993;30:237–243

2. Figueroa AA, Polley JW.Management of severe cleft maxillarydeficiency with distraction osteogenesis: procedure and re-sults. Am J Orthod Dentofac Orthop 1999;115:1–12

3. Calabrese CT, Winslow RB, Latham RA. Altering the dimen-sions of the canine face by the induction of new bone forma-tion. Plast Reconstr Surg 1974;54:467–470

4. Rachmiel A, Potparic Z, Jackson IT, et al. Midface advance-ment by gradual distraction. Br J Plast Surg 1993;46:201–207

5. Chin M, Toth BA. Distraction osteogenesis in maxillofacialsurgery using internal devices: review of five cases. J OralMaxillofac Surg 1996;54:45–53

6. Polley JW, Figueroa AA. Management of severe maxillary de-ficiency in childhood and adolescence through distraction os-teogenesis with an external, adjustable, rigid distractiondevice. J Craniofac Surg 1997;8:181–185

7. Guerrero CA, Bell WH. Intraoral distraction. In: McCarthy JG(ed). Distraction of Craniofacial Skeleton. New York: Springer,1999:219–248

8. Fairley JD,MuhlbauerW, Anderl H. Distraction of themidfaceand the zygoma. In: McCarthy JG (ed). Distraction of Cranio-facial Skeleton. New York: Springer, 1999:337–348

9. Molina F. Distraction of maxilla. In:McCarthy JG (ed). Distrac-tion of Craniofacial Skeleton. NewYork: Springer, 1999:308–320

10. Staffenberg DA,Wood RJ, McCarthy JD, et al. Midface distrac-tion advancement in the canine without osteotomies. AnnPlast Surg 1995;34:512–517

11. Cheung LK, Sammam N, Hiu E, Tiderman H. The 3-dimen-sional stability of maxillary osteotomies in cleft patientswith residual alveolar clefts. Br J Oral Maxillofac Surg1994;32:6–12

12. Posnick JC, Dagys AP. Skeletal stability and relapse patternsafter LeFort I maxillary osteotomy fixed with miniplates: theunilateral cleft lip and palate deformity. Plast Reconstr Surg1994;94:924–932

13. Polley JW, Figueroa AA. Rigid external distraction (RED): itsapplication in cleft maxillary deformities. Plast Reconstr Surg1998;102:1360–1372

14. McCarthy JG, Schreiber J, Karp N, et al. Lengthening the hu-man mandible by gradual distraction. Plast Reconstr Surg1992;89:1–8

15. Cohen SR, Burstein FD, Stewart MB, et al. Maxillary-midfacedistraction in children with cleft lip and palate: a preliminaryreport. Plast Reconstr Surg 1997;99:1421–1428

16. Holmes AD, Wright GW, Meara JG, et al. Le Fort III internaldistraction in syndromic craniosynostosis. J Craniofac Surg2002;13:262–272

17. Hata S, Itoh T, Nakagawa M, et al. Biomechanical effects ofmaxillary protraction on the craniofacial complex. Am J Or-thod Dentofac Orthop 1987;91:305–311

18. MikiM. An experimental research on the directional control ofthe nasomaxillary complex bymeans of external force: two di-mensional analysis on the sagittal plane of the craniofacialskeleton. J Tokyo Dent Coll 1979;79:1563–1597

19. Hirato R. An experimental study on the center of resistance ofnasomaxillary complex: two dimensional analysis on the coro-nal plane of the dry skull. J Tokyo Dent Coll 1984;84:1225–1262

20. Wagemans PAH, van de Velde J-P, Kuijpers-Jagtman AM. Su-tures and forces: a review. Am J OrthodDentofac Orthop 1988;94:129–141

21. McCarthy JG. Sutural expansion osteogenesis for manage-ment of the bony-tissue defect in cleft palate repair: experi-mental studies in dogs. Plast Reconstr Surg 2000;105:2012–2025, discussion, 2026–2027

22. Chong YH, Ive JC, Artun J. Changes following the use of pro-traction headgear for early correction of class III malocclusion.Angle Orthod 1996;66:351–362

23. Baccetti T, McGill JS, Franchi L, et al. Skeletal effects of earlytreatment of class III malocclusion with maxillary expansionand face-mask therapy. Am J Orthod Dentofac Orthop 1998;113:333–343

24. Smith SW, English JD.Orthodontic correction of a class IIImal-occlusion in an adolescent patientwith a bondedRPE and pro-traction face mask. Am J Orthod Dentofac Orthop 1999;116:177–183

25. Kambara T. Dentofacial changes produced by extraoral for-ward force in the Macaca irus. Am J Orthod 1977;71:249–377

26. Mermigos J, Full CA, Andreasen G. Protraction of the maxil-lofacial complex. Am J Orthod Dentofac Orthop 1990;98:47–55

27. MolstedK, Dahl E. Facemask therapy in childrenwith cleft lipand palate. Eur J Orthod 1987;9:211–215

28. Irie M, Nakamura S. Orthopedic approach to severe skeletalclass III malocclusion. Am J Orthod 1975;67:377–392

29. Nanda R. Protraction of maxilla in rhesus monkeys by con-trolled extraoral forces. Am J Orthod 1978;74:121–141

30. Kajiyama K, Murakami T, Suzuki A. Evaluation of the mod-ified maxillary protractor applied to class III malocclusionwith retruded maxilla in early mixed dentition. Am J OrthodDentofac Orthop 2000;118:549–559

31. Deguchi T, Kanomi R, Ashizawa Y, Rosenstein SW. Very earlyface mask therapy in class III children. Angle Orthod 1999;69:349–355

32. Tindlund RS. Orthopaedic protraction of the midface in thedeciduous dentition. Results covering 3 years out of treatment.J Craniomaxillofac Surg 1989;17(Suppl 1):17–19

33. Melsen B. A histological study of the influence of sutural mor-phology and skeletalmaturation on rapid palatal expansion inchildren. Trans Eur Orthod Soc 1972:499–507

34. KawakamiM, Yagi T, Takada K. Maxillary expansion and pro-traction in correction of midface retrusion in a complete uni-lateral cleft lip and palate patient. Angle Orthod 2002;72:355–361

35. Cameron CG, Franchi L, Baccetti T, McNamara JA Jr. Long--term effects of rapid maxillary expansion: a posteroanteriorcephalometric evaluation. Am J Orthod Dentofac Orthop2002;121:129–135

36. da Silva Filho OG, Montes LA, Torelly LF. Rapid maxillary ex-pansion in the deciduous and mixed dentition evaluatedthrough posteroanterior cephalometric analysis. Am J OrthodDentofac Orthop 1995;107:268–275

37. Bell RA, LeCompte EJ. The effects of maxillary expansion us-ing a quad-helix appliance during the deciduous and mixeddentitions. Am J Orthod 1981;79:152–161

38. Cleall JF, Bayne DI, Posen JM, Subtelny JD. Expansion ofthe midpalatal suture in the monkey. Angle Orthod 1965;35:23

39. Ekstrom C, Henrikson CO, Jensen R. Mineralization in themidpalatal suture after orthodontic expansion. Am J Orthod1977;71:449–455

40. Haas AJ. Long-term posttreatment evaluation of rapid palatalexpansion. Angle Orthod 1980;50:189–217

41. Brin I, Hirshfeld Z, Shanfeld JL, Davidovitch Z. Rapid palatalexpansion in cats: effect of age on sutural cyclic nucleotides.Am J Orthod 1981;79:162–175

42. Isaacson RJ, Wood JL, Ingram AH. Forces produced by rapidmaxillary expansion. Angle Orthod 1964;34:256

43. Hicks EP. Slow maxillary expansion. A clinical study of theskeletal versus dental response to low-magnitude force. AmJ Orthod 1978;73:121–141

44. Storey E. Tissue response to the movement of bones. Am JOrthod 1973;64:229–247

ODO VS SDO FOR MIDFACIAL ADVANCEMENT / Liu et al

547

44a. McCarthy JG. Epilogue. In: McCarthy JG (ed). Distraction ofthe Craniofacial Skeleton. New York: Springer; 1999:416

45. Haas AJ. Palatal expansion: just the beginning of dentofacialorthopedics. Am J Orthod 1970;57:219–255

46. Latham RA, Smiley GR, Gregg JM. The problem of tissue de-ficiency in cleft palate: an experiment in mobilizing the pala-tine bones of cleft dogs. Br J Plast Surg 1973;26:252–260

47. MeikleMC,Heath JK, HembryRM, Reynolds JJ. Rabbit cranialsuture fibroblasts under tension express a different collagenphenotype. Arch Oral Biol 1982;27:609–613

48. Yen EH, Yue CS, Suga DM. Effect of force level on synthesis oftype III and type I collagen in mouse interparietal suture. JDent Res 1989;68:1746–1751

49. Miyawaki S, Forbes DP. The morphologic and biochemicaleffects of tensile force application to the interparietal sutureof the Sprague-Dawley rat. Am J Orthod Dentofac Orthop1987;92:123–133

50. Southard KA, Forbes DP. The effects of force magnitude on asuturalmodel: a quantitative approach. Am JOrthodDentofacOrthop 1988;93:460–466

51. Gallagher RW, Miranda F, Buschang PH. Maxillary protrac-tion: treatment and posttreatment effects. Am J Orthod Den-tofac Orthop 1998;113:612–619

52. Pritchard JJ, Scott JH, Girgis FG. The structure and develop-ment of cranial and facial sutures. J Anat 1956;90:73

53. Persson M, Thilander B. Palatal suture closure in man from 15to 35 years of age. Am J Orthod 1977;72:42–52

54. Persson M, Magnusson BC, Thilander B. Sutural closure inrabbit and man: a morphological and histochemical study. JAnat 1978;125:313–321

55. Bloore JA, Furstman L, Bernick S. Postnatal development ofthe cat palate. Am J Orthod 1969;56:505–515

56. Kokich VG. Age changes in the human frontozygomatic su-ture from 20 to 95 years. Am J Orthod 1976;69:411–430

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 16, NUMBER 4 July 2005

548