C 1997 The British Assocmtion of Oral and Maxdlof:acml Surgeons

Mandibular widening by intraoral distraction osteogenesis

C. A. Guerrero, W. H. Bell*, G. 1. Contasti, A. M. Rodriguez: Centw de Cirugiu Maxilqf&ial, Curucas, Vmezuelu; * The Trxns A&M Uniw,aity Systenz-Bq,lor College qf Dentistry: DalIus, Texas, USA; P Orthodontist, Curucus, Verw~uelr; + Especinlidades Odontologicas + Los Teques, Los Teques, Venezuelu SUMMARY. Transverse mandibular deficiency with crowding of the mandibular anterior teeth is frequently present in patients with Class I and II malocclusions. The hallmarks of treatment by compensating orthodontics, functional appliances or orthopaedic devices are instability, compromised periodontium and compromised facial aesthetics. A new surgical technique has been developed to widen the mandible. The method is based upon gradual osteodistraction following vertical interdental symphyseal osteotomy. Ten patients with transverse mandibular deficiency and significant dental crowding were treated by symphyseal distraction and subsequent non-extraction decompensating orthodontic treatment. Either an intraoral tooth-borne Hyrax appliance or a new custom-made bone-borne osteodistractor was used to gradually widen the mandible. The surgical procedures were accomplished under local anaesthesia and intravenous sedation in an ambulatory surgical setting using an individualized distraction protocol. The appliances were activated 7 days after symphyseal osteotomies, once each day at a rate of 1 mm per day and stabilized for 30-60 days after distraction. After the segments were distracted, non-extraction orthodontic alignment of the mandibular anterior teeth was accomplished. The symphyseal distraction gaps were bridged by new bony regenerate. Distraction osteogenesis provided an efficient surgical alternative to orthognathic surgery for widening the mandible and treatment of transverse mandibular deficiency without extraction of teeth.

Orthodontists1m7 have long reported a high risk of dental relapse when compensating orthodontic therapy has been performed to increase the intercanine width in the presence of primary transverse bone deticiency. The skeletal type class II malocclusion is manifest in the majority of patients treated by orthodontic specialists in the USA. Despite the fact that there are many indications for treatment of transverse mandibular deficiency, dental crowding, narrow and tapered arch form, tipped teeth and missing teeth, the majority of patients with such problems receive compromised treatment by extractions, interproximal reduction of tooth mass and dental compensations. Attention to the transverse deficiency is vital in planning treatment for patients who require an increase in the lateral dimension of the mandible or maxilla. Treatment options include compensating orthodontics, functional appliances and orthopaedic devices. The hallmark of such treatment to correct the transverse discrepancy are instability, compromised periodontium created by moving teeth out of their supporting alveolar bone and compromised facial aesthetics. In a classic study of stability of mandibular alignment in first premolar extraction cases treated by traditional edgewise orthodontics, Little et al followed their cases for at least 10 years post retention.4 The results of their study indicated that there were tzo predictors of instability. Alignment was variable and unpredictable, arch width and length decreased, crowding increased and the rate of success was a meagre 30%. A similar long-term evaluation, by Little, Riedel and Artun, of changes in mandibular alignment from

10 to 20 years post retention demonstrated that continued decrease in mandibular arch length and arch correction continues after cessation of active growth. They recommended retention@ l(fti and that most premolur extraction cases are unucceptubk. The inability to control transverse maxillary deficiency prompted Strang to say that the intercanilze li?dth renmins inviolute.6 Throughout the world of orthodontics, Never expand the lower arch became a household philosophy of most practising orthodontists. Because mandibular arch form dictates maxillary arch form, the challenge remained to increase the mandibular width to compensate for arch length inadequacy, crowded anterior teeth and absolute basal bone deficiency. With the introduction of a surgical technique to widen the mandible by symphyseal osteotomy and gradual osteodistraction, the intercanine width could be increased predictably. With the use of such a technique to gradually widen the mandible based upon demonstrated biologic principles of distraction osteogenesis, many individuals with mandibular transverse deficiency can benefit from surgically assisted rapid mandibular expansion and orthodontic treatment. The transverse envelope of discrepancy for mandibular alterations can be addressed by symphyseal osteotomy and gradual osteodistraction. This treatment modality improves aesthetics and function, shortens treatment time and is stable (Fig. 1). When a skeletal or dentoalveolar deformity is so severe that the magnitude of the problem lies outside the envelope of possible correction by orthodontics alone. surgical orthodontic treatment is indicated.

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Fig. 1 -A, Widening the mandible by midline symphyseal vertical osteotomy and osteodistraction. B, Combined mandibular widening and genioplasty by osteotomy of the inferior border of the mandible.

Many of these individuals may benefit from a surgically assisted mandibular expansion and nonextraction orthodontic treatment. By utilizing the techniques described in this paper, the efficiency and flexibility of treatment greatly increase and usually preclude the need for extraction of teeth. Our present-day surgical technique of widening the mandible has been the harvest of our early clinical experiences and recent wound-healing studies.8 Although we have used the method in more than 60 patients, the surgical technique and expansion protocol have been continually evolving to our current method. Success with our surgical technique and expansion protocol prompted a report of 10 consecutive patients with transverse mandibular deficiency who were treated by mandibular widening by intraoral distraction osteogenesis.

MANDIBULAR EXPANSION: CONSIDERATIONS

ORTHODONTIC

The surgeon and orthodontist must base their diagnosis on the patients records (photographs, models, and radiographs) and individualize their treatment plan. Great flexibility is possible with this approach. Every effort is made to accomplish the planned maxillary and mandibular surgical procedures simultaneously in a single stage. Presurgical orthodontics Routine alignment, levelling and tipping orthodontic mechanics are usually not employed in the mandibular arch prior to surgery. A very rotated or tipped molar should be set upright prior to inserting the Hyrax appliance. Ideally, four bands are fixed on the appliance; the first premolars and first molars are typically used. The expansion screw of the appliance should be positioned as far anteriorly as possible to avoid tongue interference and yet maintain the appliance away from the lingual tissue. Dental compensations are not made at the orthodontic appointment prior to surgery unless the appliance is constructed immediately prior to surgery by the orthodontist. Mandibular arch Indicated decompensating orthodontic treatment of the maxillary arch is accomplished prior to placement of the Hyrax appliance in the lower arch. This assures the achievement of the desired anterior posterior position of the mandible at the time of the definitive osteodistraction.

METHOD

AND MATERIALS

Ten patients (8 women, 2 men, age 13-31, mean 20 years old) with transverse mandibular deficiency were treated by intraoral symphyseal osteotomy, mandibular expansion and subsequent non-extraction orthodontic treatment. An intraoral tooth-borne Hyrax osteodistractor appliance (8 patients) or a new boneborne appliance was used to gradually widen the anterior part of the mandible. A vertical interdental osteotomy was made between the central incisors in 7 patients, between central and lateral incisors in one patient and between the lateral incisors and canine teeth in two others. One-half (5) of the patients had simultaneous genioplasty by osteotomy of the inferior border of the mandible. All of the surgical procedures were accomplished under local anesthesia and intravenous sedation in an ambulatory outpatient clinic.

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Conventional orthodontic bands and brackets are placed in the maxillary arch, to align, level, and correct the axial inclination of the upper teeth, especially the transverse position of the buccal segments. In selected cases of transverse maxillary deficiency, a maxillary expansion appliance is used simultaneously to widen the maxilla. Once a heavy rectangular wire 16 x 22 (0.18 slots) or 18 x 25 (0.22 slots) is fixed on the maxillary arch, separators are placed on the mandibular molars and premolars to allow band litting. When it is not possible to place bands on the first molars and premolars, the second molars and premolars are used as anchorage units for the fabrication of the distraction appliance. A week after the separators are placed, the bands are fitted and impressions are taken and poured with the bands positioned on the model. The Hyrax screw is adapted to the bands, and is soldered as anteriorly and vertical as feasible to allow near-normal tongue movement and speech. One or two days before surgery, the appliance is placed on the lower arch.

interdental osteotomy site. Additionally, root length, form and position, arch width as well as periodontal integrity, are assessed. The orthodontist should achieve root divergence at the planned osteotomy sites prior to surgery to ensure that sufficient alveolar bone remains intact on both sides of the expansion gap for optimal distraction osteogenesis. This objective can be obtained either by positioning brackets to exaggerate the inclination required or by bending the arch wire. In the former case, after the expansion therapy is complete, the brackets are rebanded in the usual position. New alveolar bone will form consistently in the distraction gap when these principles are followed.

Surgical technique Rapid mandibular widening surgery is usually performed on an ambulatory basis, with the patient under intravenous sedation and local anesthesia. The horizontal incision is made with an electrocutting knife or scalpel 4-6 mm labial to the depth of the mandibular vestibule through the orbicularis oris muscle in the posterior aspect of the lower lip extending from canine to canine (Fig. 2A). After the muscle is transected, the dissection is directed obliquely, posteriorly and inferiorly through the mentalis muscle until contact is made with the mandibular symphysis. The tissues are reflected inferiorly in a subperiosteal plane to the lower border of the mandible, where a channel retractor is placed. The superior tissue flap is minimally detached subperiosteally from the planned osteotomy site at the crest of the alveolar ridge, care being taken to avoid tearing the gingival tissue. The amount of subperiosteal detachment of gingival tissue is minimized to maintain a maximum soft tissue pedicle to the segmented mandibular alveolar crest. A skin hook or similar instrument is used to reflect the flap superiorly. Generally, once the flaps are reflected, tooth root prominences can be visualized or palpated. The planned osteotomy is inscribed into the symphysis with a 701 bur. The inferior portion of the mental symphysis, below the level of the incisors, is umpletcl~~ sectioned with a reciprocating saw blade inferosuperiorly (Fig. 2A,B). The cut is usually best made by viewing the mental symphysis from an inferior perspective. With the superior margin of soft tissue flap retracted, the l~hirrl c.ortic.al plute on@ at the alveolar crest. and the labial and lingual cortices of alveolar bone immediately below the level of the incisor apices are sectioned with a No. 701 fissure bur (Fig. 2C). Finally, the symphysis is sectioned in half by gently malleting a very sharp spatula osteotome with light tapping pressure into the pwtidly sectioned interdental osteotomy site (Fig. 2 E). The forefinger is used at all times to avoid any tearing of the lingual flap. Interdentalosteotomy The osteotomy must be meticulously performed, without vertical pressure on the mandible to obviate

MANDIBULAR TECHNIQUE

EXPANSION:

SURGICAL

Mandibular transverse deficiency is treated by surgical mandibular expansion facilitated by a vertical osteotomy in the midsymphyseal or parasymphyseal area and the use of an orthopaedic expansion appliance (Fig. 2). The expansion is achieved with an appliance, which is subsequently used to maintain the space while bone healing occurs. The all-metal toothborne appliance is usually placed on the first molars and the first or second bicuspids away from the lingual mucosa. The orthodontist places the expansion appliance a few days before surgery. A bone-borne appliance may also be used to achieve mandibular expansion. In the event that a mandibular toothborne appliance becomes dislodged or breaks intraoperatively, a bone-borne osteodistractor may be used as a substitute. Selection of the osteotomy site A vital decision must be made regarding the position of the vertical interdental osteotomy site. In most cases, there is at least one interdental space with adequate bone between the roots of the teeth to facilitate an interdental osteotomy. The symphyseal osteotomy does not necessarily have to be made between the central incisors. Adequate bone between the roots of the canine and lateral incisors is frequently available. If the expansion is bilateral, the vertical osteotomy may be placed anywhere between the four mandibular anterior teeth depending on the amount of bone available between the roots. If the expansion is unilutrrul, the vertical osteotomy is made between the cuspid and the ipsilateral lower lateral incisor. A careful analysis with well-oriented periapical radiographs is made to determine the approximation of the dental roots and to select the most appropriate

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Burr SEW ,,,

Fig. 2 - Surgical technique. A, A 2.5-3 cm horizontal incision 4-6 mm labial to the depth of the mandibular vestibule is made from canine to canine. Plan of osseous surgery for interdental osteotomy in the midsymphysis region. Inferior portion of the mental symphysis, below the level of the incisors, is completely sectioned with a reciprocating saw blade (horizontal cross-hatched lines indicate where bone is sectioned by the reciprocating saw blade); with the superior margin of the soft tissue flap retracted, the labial cortical plate and alveolar bone immediately below the level of the incisor apices are sectioned with a No. 701 fissure bur (vertically oriented cross-hatched lines in B indicate where bone is sectioned with the fissure bur). B, The tissues are reflected inferiorly in a subperiosteal plane to the inferior border of the mandible, where a small channel retractor is placed. The inferior portions of the mental symphysis, below the level of the incisors, is completely (through labial and lingual cortical plates) sectioned with a reciprocating saw blade. C, The superior tissue flap is minimally detached from the planned osteotomy site at the crest of the alveolar ridge. With the superior margin of soft tissue flap retracted, the outer cortex only of the labial cortical plate of the alveolar crest is sectioned with #701 fissure bur. The labial and lingual cortices of alveolar bone immediately inferior to the level of the incisor apices are sectioned with a #701 fissure bur. Finally, the symphysis is sectioned into half by gently malleting a very sharp spatula osteotome with light tapping pressure into the partially sectioned interdental osteotomy site. D, Expansion is continued judiciously until the osteotomy is completed and the margins of the osteotomy site are separated. The teeth should be slightly separated at the end of activation. E, Simultaneous genioplasty and mandibular widening osteotomies. Osteotomy of inferior border of mandible accomplished after exposure of the mental symphysis. With the mental symphysis positioned inferiorly and the superior margin of the soft tissue flap retracted. The symphysis is divided in half by gently malleting a spatula osteotome into the partially sectioned interdental osteotomy.

displacement of the Hyrax appliance. When maxillary osteotomy or distraction are done simultaneously the maxillary surgery is accomplished first to minimize the possibility of dislodging the mandibular Hyrax

appliance. Once the osteotomy is completed, the guide pin is inserted into the expansion appliance and activated six to eight turns. Expansion is continued judiciously until the right and left segments are separated

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to assure that the interdental bone cut is complete and the margins of the osteotomy site are separated (Fig. 2D). The gingival tissue, however, should not remain blanched. If blanching occurs, the distraction is immediately discontinued and the expansion screw reversed several turns. To expand excessively might exceed the extensibility of the gingival cuff. Care must be taken to avoid tearing the tissue because this might cause a significant periodontal problem. The mentalis muscle is reattached to its origins with resorbable sutures which are placed through the muscle margins to coapt the cut edges. The mucosa is closed with interrupted plain 330 catgut sutures. The patient returns to the surgeon four to seven days after surgery to begin the distraction at the rate of 1 mm per day until the desired widening is achieved. The patient is seen every day until the expansion is completed. Two or three days later, acrylic is applied over the Hyrax screw to stabilize and maintain the expansion and for aesthetic reasons.
Simultaneous genioplasty and mandibular widening

Simultaneous repositioning of the chin and widening of the mandible are indicated in a large proportion of cases. The chin can be repositioned in any direction of space after the canines have erupted away from the planned horizontal osteotomy site. A few modifications of the technique facilitate this objective. Vertical reference lines are placed 5 mm below the canine apexes with a 701 fissure bur, to facilitate proper orientation of the chin after the osteotomy. Osteotomy of the inferior border of the mandible is extended from the first molar area of one side to the contralatera1 side, some three to four mm inferior to the mental foramen to avoid nerve injury (Fig. 2E). With the genial segment positioned inferiorly, the symphyseal osteotomy is readily accomplished by sequentially sectioning the lingual and then the labial cortices. After the distracter has been opened 2 mm, the mandibular inferior border is fixed in a routine fashion with four 0.025 stainless steel interosseous wires. The osteotomy is completed by gently malleting a tine spatula osteotomy into the planned interdental osteotomy site (Fig. 2E). Precise positioning of the interdental osteotomy in a site of adequate bone consistently produces new intermembranous bone at the site of the deficiency.
Mandibular widening

There is usually no practical limitation to the amount of mandibular expansion with the proper rate, rhythm and distraction vector. The tooth-borne expansion appliance is typically activated 8 turns at the time of surgery (2 mm) or until there is blanching of the gingival tissue. The bone-borne appliance is activated 4 turns at the time of surgery (2 mm). To avoid periodontal problems, the interdental soft tissue must not be torn. Starting five to seven days postoperatively (latency period), the patient is seen in the surgeons office every 24 h until the desired

expansion is completed (tooth-borne appliance = 4 turns, 1 mm per day; bone-borne = 2 turns, 1 mm per day). Two or three days after distraction is completed, acrylic is applied to seal the expansion screw for the stabilization period, during which the surgical movement is maintained by the appliance. After the desired mandibular widening is accomplished, brackets are bonded to the six mandibular teeth contiguous to the distraction gap. A segmented round arch wire is ligated to the bonded teeth. After an acrylic tooth similar in colour and form to the adjacent teeth is selected, the tooth with a bracket bonded to it is wired to the arch wire. Orthodontic tooth movement to close the space, however, is not attempted for the next 45-60 days. Light force is applied to the teeth adjacent to the gap as the plastic tooth is immediately reduced mesiolingually until the space is closed. The use of a coil spring and chain elastics to open space on the crowded side is required in most cases. The Hyrax orthopaedic appliance is usually maintained in position for 45-60 days after surgery. If the distraction gap regenerate is slow to form, the distraction appliance may be maintained in place for as long as three months. Periapical radiographs are taken every two weeks after distraction is completed to monitor the radiodensity of the osseous gap. Postexpansion radiographs are also a useful means of assessing the planned expansion vector. The biologic effects of stretching the periodontal ligament of the teeth contiguous to the osteotomy and the density of the postoperative radiographs are factored into the postoperative orthodontic treatment. Then the appliance and the arch are fully banded with conventional orthodontic mechanics until the lower arch is aligned and levelled, to maintain the functional arch width, for aesthetic reasons and to ensure that new bone formation repairs the distraction gap. The co-ordination of the arches and detailed finishing is accomplished by routine orthodontic mechanics. The width of the acrylic tooth is incrementally reduced as the teeth are approximated. Normally, it takes between 3 and 6 months to complete the closing movement. Co-ordination of the arches and finishing orthodontic alignment and levelling are accomplished by routine techniques. In severe mandibular transverse deticienties, when additional distraction is necessary at the end of the initial period of distraction, a second distractor is placed. With the variety of available distractor lengths, such a need is infrequent. A secondary mandibular expansion between the canines and laterals on either the right or the left side can also be considered.
Orthodontic retention

Surgical widening of the mandible in this manner increases the skeletal diameter sufficiently to accommodate all of the teeth (Fig. 3). With proper planning, compensating proclination of the anterior teeth or reduction of tooth mass by stripping is unnecessary. A lower Hawley retainer, fixed canine to canine, lingual

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Fig. 3 - Clinical case 1: Transverse mandibular deficiency and severe anterior crowding in a 28-year-old patient. A, Pretreatment occlusion. B, Panoramic radiograph showing a lingually positioned tooth-borne orthopaedic appliance and vertical parallel symphyseal gap. C, Posttreatment occlusion after 11 months of non-extraction orthodontic treatment. D, Two-month postoperative radiographic appearance after 7 mm distraction showing presence of residual bone on both sides of osteotomy.

bonded, or an Essix invisible retainer are the appliances of choice for retaining the mandibular arch width.

DISCUSSION Biologic considerations Our previous primate studies showed that new alveolar bone would form in the distraction gap and that the location of the osteotomy line in the alveolar region was vital for optimal bone regeneration.8 An adequate margin of bone contiguous with the adjacent teeth was necessary for induction of distraction osteogenesis. When the interdental osteotomy exposed the root surface of one side, new bone was formed only from the side with the intact bone interface and not from the exposed root surface. The interdental osteotomy should maintain bone on either side of the alveolus for optimal distraction osteogenesis. These experimental hypotheses are supported by the results with our present clinical techniques (Figs 3-6) The correction of transverse mandibular deficiency requires both sagittal and midline expansion osteotomies. Such procedures may cause rotational forces around the vertical axis in the temporomandibular joint and possible resultant compressive forces which exceed the adaptive capacity of the tissue.rOJr Small amounts of mandibular expansion at the symphysis using osteodistraction techniques have been shown to produce an adaptive response within the mandibular condyle. Our ongoing studies of large simultaneous widening and lengthening of the

RESULTS Ten patients underwent intraoral mandibular widening with either tooth-borne or bone-borne osteodistractor appliances. The mandible was expanded a mean of 7.7 mm (range 5-14 mm). Bony union which was observed in all patients was based upon radiographic assessment of the distraction gap. Clinically, all procedures and appliances, whether placed on the teeth (Figs 3, 5, 6) or bone (Fig. 4), were well-tolerated. The postoperative course of the patients was uneventful, without evidence of infection or devitalization of teeth contiguous to the interdental osteotomy sites. All patients were treated in an ambulatory surgical setting without the need for hospital admission. Five out of the ten patients underwent simultaneous genioplasties which were fixed with a four-wire interosseous technique without complications. One patient manifested transient temporomandibular pain and dysfunction during the stabilization period caused by occlusal instability. The symptoms disappeared after the patients occlusion was refined orthodontically.

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Fig. 4 - Clinical case 2: Transverse mandibular deficiency and severe anterior mandibular crowding in a I.?-year-old patient. .4, Pretreatment occlusion. B, Labially positioned bone-borne appliance. C, Postoperative radiograph showing vertical distraction gap (10 mm) and the osteodistractor. The surgical site was selected based on the amount of root divergence and available interdental bone. D. .4crylic was used to secure the appliance and avoid screw dislocation and bony movement at the distraction gap. E. Postoperative radiographic appearance after mandibular expansion showing distraction regenerate formed from both of the expanded segments. F, Acrylic placed over the buccal appliance with adequate transverse mavillomandibular relationship.

mandible in baboons will help to elucidate factors that are associated with these changes. To date, our clinical results have not been associated with discernible long-term temporomandibular joint dysfunction or destructive condylar changes. Previous experimental and clinical investigations have shown disproportionate movement of bone and teeth when tooth-supported osteodistraction appliances are used to widen the mandible. This paper describes the use of a new miniaturized

bone-supported intraoral osteodistraction appliance to widen the mandible (Fig. 4). Although our results are preliminary and short-term, good stability and proportionate movement of the segments was noted over the period of follow-up. In many of our early distraction patients, the Hyrax appliance was maintained in place for as long as three months to achieve stability, maintain expansion and allow for osseous repair of the distraction gap. More recently, however, the duration of the

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Fig. 5 - Clinical case 3: Anterior mandibular crowding in bilateral Brodys syndrome patient. A, Pretreatment occlusion (absolute bilateral mandibular transverse deficiency. Anterior-posterior chin deficiency was present.) B, Combined mandibular widening and advancement genioplasty. Once the screw is opened 2 mm, the lower genial segment is repositioned and fixed with four interosseous wires. The wires facilitate postoperative symphyseal expansion, C, Tooth-borne Hyrax expansion appliance in place before activation. D, Arch alignment after mandible widened more than 14 mm in two stages.The interproximal of the acrylic tooth was gradually reduced to facilitate medial orthodontic movement of the teeth; spontaneous tooth movement (walking teeth) was partially a consequence of the stretched periodontal ligaments. E, Panoramic radiographic appearance before surgery. F, Panoramic radiographic appearance 2 months post surgery.

stabilization period has been 45-60 days, based upon multiple variable factors. The age of the patient,13 rigidity of the distractor appliance, amount of expansion, quality and quantity of the host bone14 and density of the progress periapical radiographs are factored into the decision. Additional controlled

experimental and clinical studies are indicated and planned to refine the protocol. Widespread application awaits development of new miniaturized sophisticated intraoral multiplanar osteodistraction appliances with the capacity to distract the mandible three-dimensionally and monitor

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Fig. 6 -Clinical case 4: Maxillary and mandibular deficiency. A, Panoramic radiographic appearance

transverse before surgery. B. Mandibular widening by lingually positioned tooth-borne appliance after midsymphyseal osteotomy. The maxillary canines were exposed and brackets were placed simultaneously. C, Postoperative radiographic appearance I4 months after mandibular expansion showing osseous repair of distraction gap: canine teeth are normally positioned.

its movements. Precise preplanning is paramount for predictable widening of the symphysis. The position of the osteodistractor must be defined before surgery to assure adequate parallelism of the superior and inferior parts of the symphysis. The bone-borne appliance created proportionate movement of the bone and teeth. Even if the inferior portion of the symphysis widens more than the superior dentoalveolar section, expansion of the alveolar portion of the mandible may be precisely controlled by the use of a reverse action coil spring appliance to widen the alveolar portion of the mandible independently. Advantages of this surgical technique include versatility, minimal invasiveness, stability, a short procedure, and no donor site morbidity. Because all of the patients were treated in an ambulatory surgical setting with local anaesthesia and intravenous sedation without hospitalization, the cost of treatment was signilicantly reduced. Control of the mandible and its enveloping soft tissue without the use of a bone graft are additional clinical advantages. Patient compliance and the need for almost daily incremental monitoring of the distraction gap and the appliance are necessary for precise mandibular expansion. This may be an acceptable price to pay, for the disadvantages are usually outweighed by the more efficient non-extraction decompensating orthodontic treatment. Additionally, early treatment with the use of this new osteodistractor appliance may prevent both functional and psychosocial problems in many adolescents. Intraoral mandibular widening may be combined with ramus osteotomies designed to lengthen the mandible by distraction osteogenesis.

Such osteotomies could be made through developing third molar extraction sites of adolescents.
Acknowledgements
The authors wish to express their appreciation to HowmedicaLeibinger, Inc. for their support. The authors are indebted to MS Pearl Kapuscinski for her valuable assistance in preparing this manuscript.

References
I. Profitt WR. Ackerman JL. Diagnosis and treatment planning in orthodontics. In: Graber TM, Vanarsdall RL, eds. Orthodontics: Current Principles and Techniques, 2nd edn. Philadelphia: Mosby-Year Book. 1994: 3395. 2. Proflit WR, White RF? The need for surgical-orthodontic treatment. In: Proffit WR. White RP, eds. Surgical Orthodontic Treatment, 3rd edn. St. Louis: Mosby-Year Book, 1991: 2-33. 3. Wehrbein H, Bauer W, Diedrich P Mandibular incisors. alveolar bone. and symphysis after orthodontic treatment. A retrospective study. Am J Orthod Dentofac Orthop 1996: I IO: 239-246. 4. Little R, Wallen T, Riedel R. Stability and relapse of mandibular anterior alignment ~ first molar extraction cases treated by traditional edgewise orthodontics. Am J Orthod 198 I; 80: 3499365. 5. Little RM, Riedel RA, Artun J. An evaluation of changes in mandibular anterior alignment from IO to 20 years postretention. Am J Orthod Dentofdc Orthop 1988; 93: 423 428. 6. Strang RHW. A Textbook of Orthodontia. Philadelphia: Lea & Febiger, 1933. 7. Guerrero C. Rapid mandibular expansion. Rev Venez Ortod 1990; 48: I-2. 8. Bell WH, Harper RP, Gonzalez M, Cherkashin AM. Samchukov ML. Distraction osteogenesis to widen the mandible. Br J Oral Maxillofac Surg 1997; 35: I I-19.

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9. Guerrero C, Contasti G. Transverse (horizontal) mandibular deficiency. In: Bell WH, ed. Modern Practice in Orthognathic and Reconstructive Surgery, Vol. 3. Philadelphia: WB Saunders, 1992: 2383-2402. 10. Harper RP, Bell WH, Hinton RJ, Browne R, Cherkashin AM, Samchukov ML. Reactive changes in the temporomandibular joint after mandibular midline osteodistraction. Br J Oral Maxillofac Surg 1997, 35: 20-25. 11. McCormick SU, McCarthy JG, Grayson BH, Stafenberg D, McCormick SA. Effect of mandibular distraction on the temporomandibular joint: Part 1, Canine Study. J Craniofac Surg 1995; 6: 358-363. 12. Bell WH, Gonzalez M, Guerrero CA, Samchukov ML. Intraoral widening of the mandible by distraction osteogenesis: histologic and radiographic assessment. American Association of Oral and Maxillofacial Surgeons Research Abstract, 1997. 13. Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Joint Dis Orthop Inst 1988; 48: 1.

14. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. II. The influence of the rate and frequency of distraction. Clin Orthop 1989; 263: 283. The Authors Char A. Guerrero DDS Oral and Maxillofacial Surgeon and Director Centro de Cirugia Maxillofacial Gisela 1. Contasti DDS Orthodontist Centro de Cirugia Maxillofacial Centro Integral No. 105 Santa Rosa de Lima, 1060 Caracas, Venezuela William H. Bell DDS Professor Department of Oral and Maxillofacial Surgery and Pharmacology Baylor College of Dentistry Dallas, TX 752660677, USA