In a typical week, Bonnie Padwa, MD, DMD, chief
of the Oral and Maxillofacial Surgery Program at Children's Hospital Boston,
performs 15 to 20 wisdom
teeth extractions. While this comprises
a significant part of her practice, the program isn't all about extracting teeth. On any given day, Dr. Padwa might resect an oral tumor, repair a facial fracture, perform jaw
correct an underbite
or treat a child
who has a
temporomandibular joint (TMJ) disorder. In short, her team
provides a full range of services, from the routine to the complex.
One of the more involved
reconstructive procedures that the team offers is distraction osteogenesis (DO) for facial skeleton deformities, which is performed on patients from infancy through young adulthood. During this procedure, a bone is separated into two segments (osteotomy) and lengthened gradually under tension using a distraction device. The movement of the two pieces of bone results in a gap, where new bone forms.
Originally used in orthopedic
surgery to repair limb length discrepancies, DO for treatment of facial skeleton deformities has gradually gained acceptance, and according to Dr. Padwa, it has revolutionized the field of oral and maxillofacial surgery. "Before distraction, surgeons had to lengthen bones by taking bone grafts from the patient's hip, rib or cranium," she says. "This required a long operation and another operative site with the associated risks and omplications. In infants, there's a relatively small amount of bone that's available to harvest for grafts." Distraction avoids many of
these problems and significantly reduces healing time.
The department often uses DO
to correct severe micrognathia seen in patients with Robin Sequence, Treacher Collins and Nager Syndromes. Enlargement of the lower jaw brings the tongue forward, preventing it from obstructing the upper airway. Children with midface deformities, such as cleft lip and palate or more severe syndromes, such as Apert, Crouzon or Pfeiffer syndrome, also routinely benefit from DO.
The process of DO begins with
preoperative assessment. Doctors use three dimensional imaging to identify the parts of the patient's facial skeleton that need repositioning and determine the magnitude and direction of distraction. They then select the most appropriate
distraction device and sometimes have custom devises fabricated. When
possible, intraoral devices are used.
The surgery starts with an osteotomy followed by the distraction device being placed under the skin and across the osteotomy. A few days later, the two ends of the bone are very gradually pulled apart through continual adjustments that are made to the device by the parents at home. The adjustments are made by turning a small screw that extrudes through the skin, usually at a rate of 1 mm per day. This gradual distraction leads to formation of new bone between the two ends. After the process is complete, the osteotomy is allowed to heal over a period of six to eight weeks. A small second surgery is then performed to remove the device.
A wide range of conditions are diagnosed and treated by Children's Oral and Maxillofacial Program, including:
Outpatient services, such as extractions, removal of impacted teeth and placement of dental implants, are available at Children's Hospital Boston and Children's Hospital Boston at Waltham.
More information or referrals: