Maxillary and Midface Advancement With Rigid External Distraction: A Review and Technical Recommendations for Optimized Halo Placement

Background: The use of a rigid external distraction (RED) is recognized as a viable treatment option for patients with severe maxillary and midface hypoplasia. However, there is limited research on the technical placement of the RED device and its impact on patient outcomes. This systematic review examined variations in RED placement as reported in published clinical photos from journal articles, discusses its potential connection to distraction outcomes, and provides suggestions for proper placement of the device. Material and Methods: Articles in which RED was utilized and included clinical photos of patients wearing the RED device were systematically reviewed using PRISMA guidelines. Data extraction and RED placement photo assessment were performed, including subjective analysis of the images and objective angular measurement of device placement. Results: Despite the reporting of satisfactory outcomes in 83% of the reviewed articles, 64% of the photos depicted variations to the recommended halo frame placement. Of these photos, the halo frame was angled inferiorly in 73.8% and 45.16% of those studies depicting inferiorly angled halos reported adverse events. The vertical bar placement was angled posteriorly in 45% of the articles, and 44.4% of these articles reported complications. Conclusion: Photos from the literature show a high variability in RED device placement, with varying outcomes and complication rates. When placed optimally, with consideration to technical placement details such as cranial pin placement and distraction vector angles, the RED system should allow predictable maxillary and midface advancements with minimal complications.