Smaller implants and less invasive techniques for osteotomies using an endoscope assisted approach may facilitate the surgical procedures in cranio-maxillofacial distraction osteogenesis. Although sophisticated distraction devices are routinely used, there are still certain problems which need to be addressed. The preoperative planning, even of complex cases can be facilitated by using modern imaging techniques such as computer assisted surgery (CAS). The placement of the devices and the outline of complex osteotomies can be controlled intra-operatively. CAS allows for postoperative monitoring and for the long term follow up. The vector of distraction can be monitored and, depending on the device, a change of the vector of distraction may be possible during the activation period.