Distraction Osteogenesis for Craniofacial Defects

Number: 0549

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses Distraction Osteogenesis for Craniofacial Defects.

  1. Medical Necessity

    Aetna considers considers distraction osteogenesis (distraction histogenesis) medically necessary for the correction of functional impairments accompanying the following congenital craniofacial skeletal deformities:

    1. Cleft lip and palate; or
    2. Correction of hemifacial microsomia, in children with sufficient bone to allow for a corticotomy and/or osteotomy and placement of pins for external or internal distraction devices (i.e., Pruzansky Grade I and IIa type mandibular deformity); or
    3. Correction of severe congenital mandibular deficiency requiring lengthening of the mandible of greater than 10 mm (orthognathic surgery is able to correct smaller mandibular deformities); or
    4. Correction of severe micrognathia (such as accompanying Pierre Robin syndrome or Treacher Collins syndrome) in infants and children with airway obstruction; or
    5. Lengthening of a short mandibular ramus (stretching of pterygomasseteric sling); or
    6. Non-syndromic craniosynostosis – coronal (bilateral or unilateral) or sagittal; or
    7. Syndromic craniosynostosis – Apert, Crouzon, and Pfeiffer syndromes; or
    8. Widening of a narrow mandible or maxilla.

    Upon review by Aetna's Oral and Maxillofacial Surgery (OMS) Unit, distraction osteogenesis may be considered medically necessary for correction of functional impairments accompanying other congenital craniofacial anomalies where it is determined that distraction osteogenesis can uniquely produce a degree of improvement unavailable with other standard techniques.

  2. Experimental and Investigational

    The following interventions are considered experimental and investigational because the effectiveness of these approaches has not been established:

    1. Distraction osteogenesis for acquired craniofacial defects (e.g., reconstruction of defects following tumor (e.g., osteosarcoma) resection, or ablative head and neck surgery), obstructive sleep apnea, and all other craniofacial indications because of insufficient evidence regarding the clinical value of this approach for these indications.
    2. Enhancement of bone formation by means of bone morphogenetic proteins and local injection of bone marrow aspirate and platelet gel at the osteotomy site during distraction osteogenesis because of insufficient evidence in the peer-reviewed literature.

  3. Cosmetic 

    Aetna considers distraction osteogenesis for the sole purpose of improving individual appearance and profile cosmetic.

  4. Policy Limitations and Exclusions 

    Note: Aetna does not cover distraction osteogenesis (distraction histogenesis) in preparation for dental implants or orthodontic care under plans that exclude dental implants or orthodontic care. Please check benefit plan descriptions.

  5. Related Policies

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:
20692 Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)
20693 Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))
20694 Removal, under anesthesia, of external fixation system
20696 Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)
20697     exchange (ie, removal and replacement) of strut, each

CPT codes not covered for indications listed in the CPB:
0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
0481T Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed

Other CPT codes related to the CPB:
20939 Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)
21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21120 - 21196 Repair, revision, and/or reconstruction bones of face
21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)
30400 - 30462 Rhinoplasty
42200 - 42225 Palatoplasty

HCPCS codes not covered for indicationslisted in the CPB:
S9055 Procuren or other growth factor preparation to promote wound healing

Other HCPCS codes related to the CPB:
D6010 - D6199 Implant services
D7946 - D7949 LeFort procedures I, II, or III
D8010 - D8999 Orthodontic dental procedures

ICD-10 codes covered if selection criteria are met:
M26.00 - M26.59 Dentofacial anomalies [including malocclusion]
Q35.1 - Q35.9 Cleft palate
Q37.0 - Q37.9 Cleft palate with cleft lip
Q67.0 - Q67.4 Congenital deformities of skull, face and jaw
Q75.0 - Q75.9 Congenital malformation of skull and face bones [includes hemifacial microstomia]
Q87.0 Congenital malformation syndromes predominantly affecting facial appearance

ICD-10 codes not covered for indications listed in the CPB:
G47.33 Obstructive sleep apnea (adult) (pediatric)
M95.2 Other acquired deformity of head [acquired craniofacial defects]
Z41.1 Encounter for cosmetic surgery
Z46.3 Encounter for fitting and adjustment of dental prosthetic device
Z46.4 Encounter for fitting and adjustment of orthodontic device

Background

Orthognathic surgery is the surgical correction of skeletal anomalies or malformations involving the midface, mandible and maxilla.  These malformations may be present at birth, or may become evident as the patient grows and develops.  Jaw malformations can cause chewing and eating difficulties, abnormal speech patterns, early loss of teeth, and disfigurement and dysfunction of the maxilla and mandible.  Mal-occlusion may be caused by a deficiency or excess of bony tissue in one or both jaws, or by trauma to the facial bones.

In orthognathic surgery, an osteotomy is made in the affected jaw, and the bones are repositioned in a more physiologic alignment.  Generally, the bones are held in their new positions with plates, screws and wires.  The patient may also need arch bars placed on both jaws to add stability (a procedure called intermaxillary fixation).  For patients with deformities affecting both jaws, either simultaneous or staged osteotomies may be undertaken to achieve correction.  Patients with deficient bone tissue may require grafts from their ribs, hips or skull.  Alloplastic replacement of missing bone may also be required.

Indications for orthognathic surgery include:
  1. mandibular prognathism;
  2. mandibular retrognathia;
  3. maxillary excess;
  4. maxillary deficiency; and
  5. apertognathia (open bite deformity).
In some cases, adjunctive procedures such a reconstructive rhinoplasty, malar and chin osteoplasty, and bone grafting are needed to correct deformities; however these procedures require evaluation by the Oral and Maxillofacial Surgery Unit to determine coverage.  These adjunctive procedures are typically considered cosmetic in nature. 

Distraction osteogenesis, initially developed by Ilizarov for limb lengthening has recently been applied to the correction of severe congenital or acquired craniofacial deformities as an early alternative to orthognathic surgery.  Distraction osteogenesis involves the lengthening and re-shaping of deformed bone by surgical fracture and gradual separation of bony segments.  The surgeon lengthens and re-shapes deformed bone by surgically fracturing the bone and slowly separating (distracting) the resultant segments with specially fabricated hardware.  The bony fragments are held in place during the first week following surgical fracture to allow callus to form between the fragments.  During the next several weeks, the fragments are gradually separated at a rate of 1 to 2 millimeters per day, up to a pre-determined length (e.g., 20 days for 20 millimeters or 5/8 inches).  The bone segments are moved gradually to allow callus formation and adaptation of fibromuscular attachments.  Once the desired length and shape is achieved, the hardware is left in place for an additional 6 weeks until the newly formed bone calcifies.

The specially fabricated hardware used for the distraction process can be internal or external.  Advantages of external devices include ease of placement and removal.  In addition, some external devices allow multi-dimensional control.  External devices, however, are very conspicuous and are more likely to cause traction scars than internal devices.  Internal devices are less visible than external devices, and directly transmit force to the bone.  Internal devices, however, are only uni-directional and require a subsequent surgical procedure for their removal.

The primary advantage claimed in connection with distraction osteogenesis is that it allows major reshaping of the facial bones without bone grafts or jaw wiring.  Proponents claim that distraction osteogenesis may be safer than other methods of facial reconstruction, since it can involve less blood loss and a lower risk of infection.  However, according to available literature, distraction osteogenesis has several drawbacks.  If the bone ends are moved apart too slowly, callus may calcify too soon, preventing further distraction.  If the bone ends are moved apart too rapidly, callus may become too fibrous and fail to mature into solid bone.  Therefore, the rate and rhythm of distraction is important to the quality and quantity of bone that is formed.

The published literature regarding the effectiveness of distraction osteogenesis for craniofacial anomalies has focused on its use in repair of congenital conditions in young children.  The published clinical literature on distraction osteogenesis for developmental and acquired craniofacial deformities is more limited, and consists primarily of case series reporting on its technical feasibility, peri-operative morbidity, and short-term outcomes.  Orthognathic surgery is the established method of correcting developmental mandibular deficiencies, maxillary deficiencies and other developmental and acquired craniofacial deformities.  More investigation is necessary to refine distraction osteogenesis technique, to help define its role in craniofacial surgery, and to improve the design and reliability of distraction devices in repairing developmental and acquired deformities in older children and adults whose growth is at or near completion.  Moreover, there are insufficient published data on the long-term effectiveness of this procedure for these indications, especially on the rate of skeletal relapse.

According to a position statement from the American Association of Oral and Maxillofacial Surgeons (AAOMS, 2003), “the indications for distraction involving the jaws are limited to conditions in which this technique may be uniquely able to produce significant improvement over more traditional therapy.”  According to the AAOMS (2003), examples of these situations are as follows:

  • Narrow mandible that must be widened.  There has been little success in widening the mandible with conventional surgery prior to the advent of distraction.  Distraction techniques offer a better way to address this problem
  • Need for lengthening of a short mandibular ramus.  According to the AAOS, the nature of distraction osteogenesis is well-suited for stretching of the pterygomasseteric sling, which is not easily overcome by conventional procedures.
  • Severe deficiency of either jaw with early correction indicated (e.g., an infant with Pierre Robin with mandibular deficiency so severe that tracheostomy is required and advancement of the mandible is the only way to correct an obstructive situation).
  • Severe mandibular deficiency requiring lengthening of the mandible of greater than 10 mm.  Growth modification via orthodontics generally produces no more than 5 mm differential growth and conventional orthognathic procedures become more difficult and less predictable when greater than 8 to 10 mm advancement is needed.

The AAOMS guidelines also list alveolar deficiency among examples of established indications for distraction osteogenesis for craniofacial anomalies.  However, there is insufficient published evidence of the effectiveness of distraction osteogenesis for vertical augmentation of the alveolar ridge in comparison with grafting techniques for this indication.

The AAOMS guidelines list “[w]idening of the maxilla in an adult” among established indications for distraction osteogenesis.  However, surgically assisted palatal expansion, which is analogous to distraction osteogenesis, has been utilized to overcome this problem for decades with very desirable and stable results".

AAOMS guidelines note that, “[a]s with any procedure, distraction osteogenesis should be utilized primarily when superior results can be achieved compared to conventional techniques” (AAOMS, 2003).

Although the AAOMS guidelines do not distinguish between congenital and developmental and acquired conditions, the published evidence to date has focused on repair of congenital conditions.  There is insufficient evidence of the effectiveness of distraction osteogenesis for developmental and acquired craniofacial anomalies.

Schreuder et al (2007) noted that bilateral sagittal split osteotomy (BSSO) and distraction osteogenesis are the most common techniques currently applied to surgically correct mandibular retrognathia.  These investigators reviewed the literature on BSSO and mandibular distraction osteogenesis with emphasis on the influence of age and post-surgical growth, damage to the inferior alveolar nerve, and post-surgical stability and relapse.  Although randomized clinical trials are lacking, some support was found in the literature for distraction osteogenesis having advantages over BSSO in the surgical treatment of low and normal mandibular plane angle patients needing greater advancement (greater than 7 mm).  In all other mandibular retrognathia patients the treatment outcomes of distraction osteogenesis and BSSO seemed to be comparable.  Distraction osteogenesis is accompanied by greater patient discomfort than BSSO during and shortly after treatment, but it is unclear if this has any consequences in the long-term.  There is a need for randomized clinical trials comparing the 2 techniques in all types of mandibular retrognathia, in order to provide evidence-based guidelines for selecting which retrognathia cases are preferably treated by BSSO or distraction osteogenesis.

Sacco and Chepeha (2007) stated that earlier work has reported encouraging results regarding the translation of distraction osteogenesis from animal studies to human uses, with particular success in the un-radiated setting.  The major challenge surrounding the use of this technology in head and neck oncological reconstruction will be the effect of radiotherapy on the regenerate bone in patients who have received or will need radiotherapy as part of their treatment.  Although distraction osteogenesis provides an attractive option for reconstructing mandibular defects, large human studies are needed to further evaluate the use of this technology and its role in the treatment for mandibular neoplasms.

Ow and Cheung (2008) stated that mandibular distraction osteogenesis has been used effectively to treat syndromic craniofacial deformities.  In recent years, its scope of application has widened to include treatment of airway obstruction in adults and children as well as non-syndromic class II mandibular hypoplasia.  So far, there has been no evidence-based review of mandibular distraction osteogenesis for mandibular lengthening.  These investigators carried out a meta-analysis of mandibular distraction osteogenesis.  Two rounds of searches were performed by 2 independent assessors.  The first-round PubMed search used the keywords "mandible" and "distraction osteogenesis".  In the second-round search, the reference lists of the articles were retrieved.  For both rounds, abstracts and then full articles were reviewed and selected on the basis of a set of inclusion and exclusion criteria.  The 178 retrieved articles yielded 1,185 mandibular distraction osteogenesis patients: 539 received unilateral mandibular distraction osteogenesis and 646 received bilateral mandibular distraction osteogenesis.  Mandibular distraction osteogenesis was reported to improve facial asymmetry and retrognathia (50.1 %), correct the slanted lip commissure (24.7 %), and improve or level the mandibular occlusal plane (11.1 %) in unilateral asymmetry cases, whereas bilateral mandibular distraction osteogenesis was shown to be effective in preventing tracheostomies for 91.3 % of neonates or infants with respiratory distress, and in relieving symptoms of obstructive sleep apnea for 97.0 % of children and 100 % of adult patients.  The authors concluded that mandibular distraction osteogenesis is effective in treating craniofacial deformities, but further clinical trials are needed to evaluate the long-term stability and to compare the treatment with conventional treatment methods, especially in cases of obstructive sleep apnea or class II mandibular hypoplasia.

In a retrospective medical review spanning a 9-year period, Kolstad and colleagues (2011) examined if there is a difference in mandibular distraction osteogenesis (MDO) treatment success rates and adverse outcomes in newborns, early infants, and older pediatric patients.  Ten newborn (less than or equal to 35 days old), 5 early infant (36 days to 5 months) and 8 older pediatric (greater than 5 months) patients underwent MDO for treatment of micrognathia with a severe tongue-based obstruction.  Success was defined as avoidance of tracheostomy or continuous positive airway pressure, and de-cannulation of patients with tracheotomies.  Post-operative complications were grouped into minor and major.  MDO successfully treated 90 % of newborns, 100 % of early infants and 100 % of older pediatric patients.  There was no difference in the rates of success (p = 0.48), minor (p = 1.00) and major (p = 1.00) post-operative complications between newborns and early infants.  Older pediatric patients had no treatment failures, tended to have fewer minor (p = 0.18) and significantly fewer major (p = 0.04) post-operative complications compared to younger patients.  The distractor pin mobility (9 %) and scar revisions (13 %) were uncommon.  The authors concluded that MDO is a reliable method for relieving severe tongue-based obstructions in pediatric patients.  When comparing newborns and early infant patients, treatment success rates and the occurrence of complications were not found to be different.  Older pediatric patients had no treatment failures, and tended to have fewer post-operative complications compared to younger patients.

Pluijmers et al (2014) provided an overview of the surgical correction of the mandible in unilateral craniofacial microsomia (UCM) performed in the growing patient, and its long-term outcome and stability.  The following databases were searched: PubMed, Embase, Cochrane, and Web of Science.  Articles reporting prospective and retrospective studies of patients not older than 16 years (n ≥ 4) who had undergone surgical correction of a craniofacial microsomia spectrum condition using grafts, osteotomies, distraction, or combinations of these, were reviewed.  The period of follow-up was selected to be greater than or equal to 1 year.  After inclusion, the articles were evaluated on short- and long-term outcomes, relapse, and any increase in asymmetry following treatment; 30 of 1,611 articles were included in the qualitative synthesis.  Analysis of the surgical mandibular correction of UCM showed that the outcome is not so much treatment-dependent, but patient-dependent, i.e., deformity gradation-dependent.  The type I and type IIa Pruzansky-Kaban patient had the best results with regard to minimal relapse and/or minimal increase in asymmetry.  Single-stage correction of the asymmetry should be postponed until the permanent dentition stage. The authors concluded that in the treatment of the severely hypoplastic mandible, the patient will benefit from a multi-stage treatment protocol if indicated for functional or psychological problems.

Tahiri et al (2014) stated that distraction osteogenesis is an effective technique for elongating the deficient mandible.  These investigators evaluated its effectiveness in the treatment of airway obstruction in pediatric patients with mandibular hypoplasia.  A comprehensive literature review of the National Library of Medicine (PubMed) database was performed.  English-language studies involving isolated distraction of the pediatric mandible (younger than 18 years) with descriptive reporting of airway changes were included.  Extracted data included demographics, initial diagnosis, distractor type, distraction protocol, pre-distraction and post-distraction airway status, and complications.  A total of 74 articles met the inclusion criteria, resulting in 711 patients with craniofacial abnormalities who underwent mandibular distraction osteogenesis.  Mean age at the time of distraction was 18.1 months.  The most common diagnoses were isolated Pierre Robin sequence (52.9 %), syndromic Pierre Robin sequence (7 %), and Treacher Collins syndrome (6.8 %).  Mandibular distraction osteogenesis successfully treated airway obstruction in 89.3 % of cases.  Success was defined as either de-cannulation of tracheostomy, avoidance of tracheostomy or continuous positive airway pressure, or alleviation or significant improvement of obstructive sleep apnea (OSA) symptoms.  A total of 171 (84.2 %) of the 203 tracheostomy-dependent patients were successfully de-cannulated.  Among the 181 patients with OSA, mandibular distraction osteogenesis successfully allowed for either complete resolution or significant improvement of symptoms in 95.6 %.  A 23.8 % overall complication rate was noted.  The mean follow-up time was 28.7 months.  The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients.

Bone Morphogenetic Proteins

Sabharwal and colleagues (2011) notd that delayed bone healing during distraction osteogenesis negatively affects clinical outcome.  In addition to autologous bone grafting, several mechanical, chemical, biologic, and external treatment modalities may be employed to promote bone growth during distraction osteogenesis in the pediatric patient.  Mechanical approaches include compressive loading of the distraction regenerate, increased frequency of small increments of distraction, and compression-distraction.  Intra-medullary nailing and sub-muscular plating can reduce the time in external fixation; however, these techniques are associated with technical difficulties and complications.  Exogenous application of low-intensity pulsed ultrasound or pulsed electromagnetic fields may shorten the duration of external fixation.  Other promising modalities include diphosphonates, physician-directed use (off-label use) of bone morphogenetic proteins, and local injection of bone marrow aspirate and platelet gel at the osteotomy site.  The author concluded that well-designed clinical studies are needed to establish safe and effective guidelines for various modalities to enhance new bone formation during distraction osteogenesis in children.

Terbish and colleagues (2015) evaluated the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) on the quality and quantity of regenerated bone when injected into distracted alveolar bone. A total of 16 adult beagle dogs were assigned to either the control or rhBMP-2 group.  After distraction was completed, an rhBMP-2 dose of 330 μg in 0.33 ml was injected slowly into the distracted alveolar crest of the mesial, middle, and distal parts of the alveolar bone in the experimental group.  Histologic and micro-computed tomography analyses of regenerated bone were done after 2 and 6 weeks of consolidation.  After 6 weeks of consolidation, the vertical defect height in the middle of the regenerated bone was significantly lower in the rhBMP-2 group (2.2 mm) than in the control group (3.4 mm) (p < 0.05).  Additionally, the width of the regenerated bone was significantly greater in the rhBMP-2 group (4.3 mm) than in the control group (2.8 mm) (p < 0.05).  The bone density and volume of regenerated bone in the rhBMP-2 group were greater than in the control group after 6 weeks of consolidation (p < 0.001).  The authors concluded that injection of rhBMP-2 into regenerated bone after a distraction osteogenesis procedure significantly increased bone volume in the dento-alveolar distraction site and improved both the width and height of the alveolar ridge and increased the bone density.  These preliminary findings from a canine model need to be examined in human subjects.

Distraction Osteogenesis of the Irradiated Craniofacial Skeleton

Momeni and colleagues (2017) stated that craniofacial DO is a common treatment modality today.  Despite its numerous advantages, however, concerns have been expressed regarding the use of DO in the irradiated setting.  A systematic review was performed to identify all published reports of patients who underwent DO of the irradiated craniofacial skeleton.  The following parameters were of particular interest: post-operative complications, specifically, insufficient bone formation, fracture, and hardware exposure (intra-oral and cutaneous), as well as the need for additional bone grafting.  The initial search retrieved a total of 183 articles of which 20 articles (38 patients) met pre-determined inclusion criteria.  The most common site of distraction was the mandible (76.3 %).  The median radiation dose was 50.7 Gy (range of 30 to 70 Gy).  Bone defects ranged from 30 to 80 mm (median of 42.5 mm).  Complications were encountered in 19 patients (50 %), with insufficient bone formation being most common (9 patients; 23 %).  The overall incidence of complications was not significantly associated with radiation dosage (p = 0.79).  The remaining procedural and demographic variables also failed to meet statistical significance when compared against the overall complication rate (p = 0.27 to 0.97).  The authors concluded that the complication rate associated with craniofacial DO of the irradiated skeleton did not appear to be substantially higher than what was reported for DO in the non-irradiated setting.  As such, patients should be offered this treatment modality, particularly in light of the fact, that it offers the option to decrease patient morbidity as well as treatment complexity.

References

The above policy is based on the following references:

  1. Al-Namnam NMN, Hariri F, Rahman ZAA. Distraction osteogenesis in the surgical management of syndromic craniosynostosis: A comprehensive review of published papers. Br J Oral Maxillofac Surg. 2018;56(5):353-366.
  2. American Association of Oral and Maxillofacial Surgeons (AAOMS). Distraction osteogenesis. Statements by the American Association of Oral and Maxillofacial Surgeons Concerning the Management of Selected Clinical Conditions and Associated Clinical Procedures. Rosemont, IL: AAOMS; July 2003. Available at: http://www.aaoms.org/allied/pdfs/distraction.pdf. Accessed October 16, 2003.
  3. Anehosur V, Monis PL, Nagaraj N, et al. Role of distraction osteogenesis in the management of postankylotic deformity. J Craniofac Surg. 2022;33(8):2493-2498.
  4. Balaji SM, Balaji P. Comparison of midface advancement by external and internal craniofacial distraction osteogenesis. Ann Maxillofac Surg. 2018;8(2):200-205.
  5. Breik O, Tivey D, Umapathysivam K, Anderson P. Mandibular distraction osteogenesis for the management of upper airway obstruction in children with micrognathia: A systematic review. Int J Oral Maxillofac Surg. 2016;45(6):769-782.
  6. Breik O, Umapathysivam K, Tivey D, Anderson P. Feeding and reflux in children after mandibular distraction osteogenesis for micrognathia: A systematic review. Int J Pediatr Otorhinolaryngol. 2016;85:128-135.
  7. Cano J, Campo J, Moreno LA, Bascones A. Osteogenic alveolar distraction: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(1):11-28.
  8. Chanchareonsook N, Samman N, Whitehill TL. The effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status: A critical review. Cleft Palate Craniofac J. 2006;43(4):477-487.
  9. Chua HD, Hägg MB, Cheung LK. Cleft maxillary distraction versus orthognathic surgery--which one is more stable in 5 years? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(6):803-814.
  10. Cohen SR, Burstein FD, Williams JK. The role of distraction osteogenesis in the management of craniofacial disorders. Ann Acad Med Singapore. 1999;28(5):728-738.
  11. Denny AD, Kalantarian B, Hanson PR. Rotation advancement of the midface by distraction osteogenesis. Plast Reconstr Surg. 2003;111(6):1789-1799; discussion 1800-1803.
  12. Diner PA, Tomat C, Soupre V, et al. Intraoral mandibular distraction: Indications, technique and long-term results. Ann Acad Med Singapore. 1999;28(5):634-641.
  13. Engel M, Berger M, Hoffmann J, et al. Midface correction in patients with Crouzon syndrome is Le Fort III distraction osteogenesis with a rigid external distraction device the gold standard? J Craniomaxillofac Surg. 2019;47(3):420-430. 
  14. Enislidis G, Fock N, Ewers R. Distraction osteogenesis with subperiosteal devices in edentulous mandibles. Br J Oral Maxillofac Surg. 2005;43(5):399-403.
  15. Erler K, Yildiz C, Baykal B, Reconstruction of defects following bone tumor resections by distraction osteogenesis. Arch Orthop Trauma Surg. 2005;125(3):177-183.
  16. Figueroa AA, Polley JW, Friede H, Ko EW. Long-term skeletal stability after maxillary advancement with distraction osteogenesis using a rigid external distraction device in cleft maxillary deformities. Plast Reconstr Surg. 2004;114(6):1382-1392; discussion 1393-1394.
  17. Figueroa AA, Polley JW. Management of severe cleft maxillary deficiency with distraction osteogenesis: Procedures and results. Am J Orthod Dentofac Orthop. 1999;115:1-12.
  18. Gaggl A, Schultes G, Karcher H. Distraction implants: A new operative technique for alveolar ridge augmentation. J Craniomaxillofac Surg. 1999;27(4):214-221.
  19. Gao W-L, Lee Y-H, Tsai C-Y, et al. One-year treatment outcome of profile changes after transcutaneous maxillary distraction osteogenesis in growing children with cleft lip and palate. Cleft Palate Craniofac J. 2022;59(3):299-306.
  20. Gateno J, Teichgraeber JF, Aguilar E. Distraction osteogenesis: A new surgical technique for use with the multiplanar mandibular distractor. Plast Reconstr Surg. 2000;105(3):883-888.
  21. Genecov DG, Barceló CR, Steinberg D, et al. Clinical experience with the application of distraction osteogenesis for airway obstruction. J Craniofac Surg. 2009;20 Suppl 2:1817-1821.
  22. Guerrero CA, Bell WH, Contasti GI, et al. Mandibular widening by intraoral distraction osteogenesis. Br J Oral Maxillofac Surg. 1997;35:383-392.
  23. Imola MJ, Hamlar DD, Thatcher G, et al. The versatility of distraction osteogenesis in craniofacial surgery. Arch Facial Plast Surg. 2002;4(1):8-19.
  24. Imola MJ. Craniofacial distraction osteogenesis. eMedicine Otolaryngology and Facial Plastic Surgery, Topic 702. Omaha, NE: eMedicine.com; updated May 14, 2002.
  25. Jensen OT. Distraction osteogenesis and its use with dental implants. Dent Implantol Update. 1999;10(5):33-36.
  26. Klein C, Howaldt HP. Correction of mandibular hypoplasia by means of bidirectional callus distraction. J Craniofac Surg. 1996;7:258-266.
  27. Kolstad CK, Senders CW, Rubinstein BK, Tollefson TT. Mandibular distraction osteogenesis: At what age to proceed. Int J Pediatr Otorhinolaryngol. 2011;75(11):1380-1384.
  28. Kunkel M, Wahlmann U, Reichert TE, et al. Reconstruction of mandibular defects following tumor ablation by vertical distraction osteogenesis using intraosseous distraction devices. Clin Oral Implants Res. 2005;16(1):89-97.
  29. Liou EJ, Huang CS. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofac Orthop. 1998;114:372-382.
  30. Marquez IM, Fish LC, Stella JP. Two-year follow-up of distraction osteogenesis: Its effect on mandibular ramus height in hemifacial microsomia. Am J Orthod Dentofacial Orthop. 2000;117(2):130-139.
  31. Matsubara H, Tsuchiya H, Sakurakichi K, et al. Distraction osteogenesis of a previously irradiated femur with malignant lymphoma: A case report. J Orthop Sci. 2005;10(4):430-435.
  32. Mehrara BJ, Longaker MT. New developments in craniofacial surgery research. Cleft Palate Craniofac J. 1999;36(5):377-387.
  33. Meling TR, Hogevold HE, Due-Tonnessen BJ, Skjelbred P. Midface distraction osteogenesis: Internal vs. external devices. Int J Oral Maxillofac Surg. 2011;40(2):139-145.
  34. Momeni A, Januszyk M, Wan DC. Is distraction osteogenesis of the irradiated craniofacial skeleton contraindicated? J Craniofac Surg. 2017;28(5):1236-1241.
  35. Mommaerts MY. Reliability and validity of a backlighted digitizer when used for craniofacial measurements. J Craniofac Surg. 1997;8:222-228.
  36. Oda T, Sawaki Y, Ueda M. Experimental alveolar ridge augmentation by distraction osteogenesis using a simple device that permits secondary implant placement. Int J Oral Maxillofac Implants. 2000;15(1):95-102.
  37. Ow AT, Cheung LK. Meta-analysis of mandibular distraction osteogenesis: Clinical applications and functional outcomes. Plast Reconstr Surg. 2008;121(3):54e-69e.
  38. Patel PK, Han H. Craniofacial, distraction osteogenesis. eMedicine Plastic Surgery, Topic 459. Omaha, NE: eMedicine.com; updated February 1, 2002.
  39. Pluijmers BI, Caron CJ, Dunaway DJ, et al. Mandibular reconstruction in the growing patient with unilateral craniofacial microsomia: A systematic review. Int J Oral Maxillofac Surg. 2014;43(3):286-295.
  40. Rachmiel A, Aizenbud D, Eleftheriou S, et al. Extraoral vs. intraoral distraction osteogenesis in the treatment of hemifacial microsomia. Ann Plast Surg. 2000;45(4):386-394.
  41. Raghoebar GM, Jansma J, Vissink A, Roodenburg JL. Distraction osteogenesis in the irradiated mandible. A case report. J Craniomaxillofac Surg. 2005;33(4):246-250.
  42. Rubio-Bueno P, Naval L, Rodriguez-Campo F, et al. Internal distraction osteogenesis with a unidirectional device for reconstruction of mandibular segmental defects. J Oral Maxillofac Surg. 2005;63(5):598-608.
  43. Sabharwal S. Enhancement of bone formation during distraction osteogenesis: Pediatric applications. J Am Acad Orthop Surg. 2011;19(2):101-111.
  44. Sacco AG, Chepeha DB. Current status of transport-disc-distraction osteogenesis for mandibular reconstruction. Lancet Oncol. 2007;8(4):323-330.
  45. Saltaji H, Altalibi M, Major MP, et al. Le Fort III distraction osteogenesis versus conventional Le Fort III osteotomy in correction of syndromic midfacial hypoplasia: A systematic review. J Oral Maxillofac Surg. 2014;72(5):959-972.
  46. Samchukov ML, Cope JB, Harper RP, et al. Biomechanical considerations of mandibular lengthening and widening by gradual distraction using a computer model. J Oral Maxillofac Surg. 1998;56(1):51-59.
  47. Shaw WC, Mandall NA, Mattick CR. Ethical and scientific decision making in distraction osteogenesis. Cleft Palate Craniofac J. 2002;39(6):641-645.
  48. Shirai T, Tsuchiya H, Yamamoto N, et al. Successful management of complications from distraction osteogenesis after osteosarcoma resection: A case report. J Orthop Sci. 2004;9(6):638-642.
  49. Swennen G, Dempf R, Schliephake H. Cranio-facial distraction osteogenesis: A review of the literature. Part II: Experimental studies. Int J Oral Maxillofac Surg. 2002;31(2):123-135.
  50. Swennen G, Schliephake H, Dempf R, et al. Craniofacial distraction osteogenesis: A review of the literature: Part 1: Clinical studies. Int J Oral Maxillofac Surg. 2001;30(2):89-103.
  51. Tahiri Y, Viezel-Mathieu A, Aldekhayel S, et al. The effectiveness of mandibular distraction in improving airway obstruction in the pediatric population. Plast Reconstr Surg. 2014;133(3):352e-359e.
  52. Terbish M, Yoo SH, Kim HJ, et al. Accelerated bone formation in distracted alveolar bone after injection of recombinant human bone morphogenetic protein-2. J Periodontol. 2015;86(9):1078-1086.
  53. Tillery DE Jr. Advances in orthognathic surgery. Dent Today. 1998;17(8):90-92.
  54. Van Sickels JE. Distraction osteogenesis versus orthognathic surgery. Am J Orthod Dentofacial Orthop. 2000;118(5):482-484.
  55. van Strijen PJ, Perdijk FB, Becking AG, et al. Distraction osteogenesis for mandibular advancement. Int J Oral Maxillofac Surg. 2000;29(2):81-85.
  56. Verstraaten J, Kuijpers-Jagtman AM, Mommaerts MY, et al.; Eurocran Distraction Osteogenesis Group. A systematic review of the effects of bone-borne surgical assisted rapid maxillary expansion. J Cranio-Maxillo-Facial Surg. 2010;38(3):166-174.
  57. Zhai J, Wang B, Xu M, et al. A 3-dimensional measurements of bone and airway variables after Le Fort I distraction osteogenesis in patients with cleft lip and/or palate-induced midface hypoplasia: A retrospective study. J Craniofac Surg. 2023;34(2):584-590.