Comparison of intraoral and extraoral approaches for placement of mandibular distractors in adolescents: anatomical, surgical, and aesthetic considerations

Relevance. Mandibular hypoplasia in adolescents poses significant functional and aesthetic challenges. Mandibular distraction osteogenesis (DO) enables gradual bone lengthening with new bone formation and remains an effective treatment modality with low relapse rates. However, the choice of surgical approach for distractor placement—intraoral versus extraoral–remains a subject of debate. Each approach entails distinct anatomical, surgical, and aesthetic considerations. The intraoral approach avoids visible scarring, which is especially important for adolescents, whereas the extraoral approach is technically straightforward in severe deformities and permits greater distraction length. Objective. To compare intraoral and extraoral mandibular distraction in adolescents by analyzing anatomical landmarks, surgical techniques, complication rates, and aesthetic out-comes, and to develop clinical recommendations for selecting the optimal approach. Materials and methods. A literature review was conducted using relevant sources from the PubMed, Scopus, Web of Science, and Google Scholar databases published within the past 10 years, focusing on mandibular distraction osteogenesis in children and adolescents. The following key parameters were compared: surgical approach, distraction vector and magnitude, treatment duration, complication rates, and aesthetic outcomes. Two summary tables are presented: (1) a comparative analysis of intraoral and extraoral approaches, and (2) an overview of distraction protocols and outcomes reported in various studies. Results. Intraoral distractors are placed through an intraoral incision and typically feature curvilinear activation, allowing simultaneous vertical and horizontal mandibular lengthening with concealed hardware and no visible external scars. This approach is associated with fewer postoperative complications (~10% vs. 30–40%) and infrequent neurosensory disturbances, although it generally achieves a slightly smaller mean elongation (approximately 10–15 mm) compared to extraoral systems. Extraoral distractors require a submandibular incision and external activation units, enabling greater distraction length (~15–20 mm or more) and precise vector control. However, they are associated with higher risks of hypertrophic scarring, pin-site infections, and transient facial nerve paresis. Adolescent patients tend to tolerate intraoral distractors better due to improved comfort and aesthetics. Recent studies have shown no significant differences in treatment success or airway improvement between approaches when distraction parameters remain within device capabilities; however, intraoral systems demonstrate higher reliability (fewer mechanical failures) and a lower overall scar burden. Conclusion. Mandibular distraction osteogenesis is a reliable treatment modality for mandibular hypoplasia in children and adolescents with incomplete facial skeletal growth. The intraoral approach is preferable for moderate deformities, providing superior aesthetic outcomes and fewer complications. The extraoral approach remains justified for severe deficiencies requiring maximal elongation or complex vector adjustment, particularly in cases with limited mouth opening. Clinical recommendations are proposed to individualize surgical access selection based on deformity severity, anatomical constraints, and aesthetic considerations.