Mechanical force optimization for craniofacial distraction osteogenesis: current concepts and future direction — a comprehensive review of the literature

INTRODUCTION: Distraction osteogenesis is a fundamental surgical intervention for patients with complex craniofacial conditions such as syndromic craniosynostosis, mandibular micrognathia, and midface hypoplasia. Yet, its clinical implications continue to rely on empirical protocols lacking quantitative biomechanical foundations. AREAS COVERED: In this review, we present a comprehensive synthesis of the current literature on force, torque, viscoelastic soft tissue resistance, and regenerate mechanics during craniofacial distraction osteogenesis based on a comprehensive literature search on PubMed, Scopus, Web of Science, Embase, and Google Scholar. Across cranial, maxillary, and mandibular distraction, we identified pronounced regional heterogeneity in mechanical demands, with cranial vault distraction requiring far greater torque and force than either maxillary or mandibular distraction. Importantly, the magnitudes of force and torque measured across the craniofacial skeleton are substantially lower than those presumed to guide current distractor engineering, revealing a significant opportunity for miniaturized, fully-internalized bioresorbable systems. EXPERT OPINION: We established a quantitative framework for a mechanobiologically optimized craniofacial distraction, providing the conceptual and engineering basis for anatomy-specific, feedback-regulated, next-generation distraction devices and patient-tailored distraction protocols.