published_or_final_version / Dentistry / Doctoral / Doctor of Philosophy

Background Distraction osteogenesis (DO) was first applied on the human craniofacial skeleton in 1992 by McCarthy et al.1 who performed lengthening of the mandible in patients with hemifacial microsomia and Nager’s syndrome. Further advances in this field have since then led to the widespread use of this modality for the treatment of numerous congenital and acquired craniofacial skeletal anomalies. In 2001, a review by Swennen et al2 concluded that up to year 1999, this form of treatment was gaining intense popularity but that the main drawbacks included insufficient data on long term results and relapse. A systematic review of the last decade on functional outcomes and long term complications following distraction osteogenesis of the facial skeleton is presented. Methods A structured systematic literature search, with predefined inclusion and exclusion criteria from relevant computer databases and journals were performed. The journals were evaluated and critically appraised by 2 reviewers separately in 3 rounds. Papers were categorized according to the level of evidence, the quality of methodology and the specific field of functional outcomes and long term complications. Results were then categorized according to the type of distraction movements, ie maxillary advancement and mandibular lengthening. Results A total of 42 papers comprising of 16 studies for maxillary advancement and 26 studies for mandibular lengthening were included in this review. Maxillary advancement was found to be beneficial in patients with cleft maxillary hypoplasia in terms of achieving aesthetic outcome but the risk for velopharyngeal insufficiency remains uncertain. The achieved maxillary advancement was stable if performed on adult patients while a recurrence of midface retrusion was noted if DO was performed on growing patients. Overcorrection was recommended in these cases to an estimated value of 20-50%. Mandibular lengthening was 99% successful in relieving respiratory obstruction in patients with isolated Pierre Robin Sequence (PRS) or syndromic micrognathic infants preventing the need for tracheostomy in the long term, and in 89% successfully decannulating infants with pre-existing tracheostomy. However, feeding and growth outcomes after airway obstruction was relieved remain unknown due to lack of sufficient evidence. Unilateral mandibular DO was successful in achieving aesthetic symmetrical facial balance in patients with hemifacial microsomia however a total loss of corrected distraction length was noted by the end of growth period if DO was performed during growth. Conclusions DO achieved stable results in terms of lengthening the maxilla and mandible but was also noted to cause restricted growth potential of the distracted bone. Hence, the benefits of performing DO during active growth should be weighed against the likely need for a second surgery due to a growth deficit of distracted bone and future surrounding bone growth. However DO in adults remains an alternative to conventional orthognathic surgery and choice of treatment should be patient centred. / published_or_final_version / Dental Surgery / Master / Master of Dental Surgery

This inquiry investigated the suitability of the jaw of domestic sheep as an animal model for dental implantology research. Initially, parameters for osseous healing of critical size defects (CSD) in the sheep mandible were established. Pilot studies were conducted using machined-surface implants and a surgical protocol established for dental implant placement in ovine mandibular sites. Subsequent experiments considered the utility of this animal model for examination of techniques designed to enhance osseointegration. Hydroxyapatite-coated implants were compared with titanium plasma-sprayed (TPS) implants, either alone or combined with autogenous bone grafts or a bone graft/collagen vehicle loaded with transforming growth factor-beta (TGF-β). Immunofluorescent bone labelling gave information on the mineral apposition rate (MAR). Implant survival and "acceptability" (likelihood of clinical success) were major output variables, along with histomorphometric analysis of percent bone-implant contact (%BIC) and percent peri-implant bone density (%density). Naturally-occurring "broken-mouth" periodontitis in sheep was identified as a potential confounder. Subsequent experiments considered implants with different surfaces. The model was also extended from a two-stage surgical protocol to include single-stage implants. The effect of pre-existing ovine peridontitis was also examined. A systematic review and meta-analysis of published animal implant experiments was conducted in order to validate the candidate sheep model. Major findings were as follows. The size of non-healing sheep mandibular unicortical CSD is >12mm. Attempts to establish a chronic non-healing CSD were unsuccessful. The sheep diastema proved unsuitable for implant placement. The model was modified to a post-extraction protocol. Implant "acceptability" rates after 3 months integration in the sheep mandible (defined as implant survival with %BIC >10%) ranged from 50% - 100% for different implant surface treatments and placement protocols. Histomorphometriic analyses revealed that %BIC ranged from 11 � 17% to 81 � 29 % for different titanium surfaces and up to 85 � 11% for hydroxyapatite surfaces. Implants with TGF-β plus autogenous bone grafts had %BIC of 36 � 30% compared with 43 � 30% for implants with grafts alone. Bone per unit area (%density) adjacent to, but outside of the implant threads, ranged from 63 � 16% to 86 � 3% and was markedly lower for titanium plasma-sprayed surfaces and for one-stage implants. Within the implant threads, %density varied from 31 � 33% to 73.4 � 8.3%, and was markedly lower for machined titanium surfaces. Sheep periodontitis had little effect on the protocols investigated. The sheep mandibular model was found to be comparable to similar models in other species and merits further development.

Thesis (M.S.)--University of Michigan, 1968.

Thesis (M.S.)--University of Michigan, 1969.

Thesis (M.S.)--University of Michigan, 1983.

Thesis (M.S.)--University of Michigan, 1955.

Thesis (M.S.)--University of Michigan, 1983.

Thesis (M.S.)--University of Michigan, 1968.

Thesis (M.S.)--University of Michigan, 1969.